Basic Information
Provider Information | |||||||||
NPI: | 1598205221 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARATHON HEALTH, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARATHON HEALTH AT BREVARD SOUTH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 WINOOSKI FALLS WAY STE 400 | ||||||||
Address2: |   | ||||||||
City: | WINOOSKI | ||||||||
State: | VT | ||||||||
PostalCode: | 054042239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028570434 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2550 WINGATE BOULEVARD | ||||||||
Address2: | C/O BREVARD WELLCARE- SOUTH | ||||||||
City: | WEST MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 32904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028570400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2017 | ||||||||
LastUpdateDate: | 02/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORD | ||||||||
AuthorizedOfficialFirstName: | JERRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8028570400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MARATHON HEALTH, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.