Basic Information
| Provider Information | |||||||||
| NPI: | 1629013966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARCELLUS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1150 STATE HIGHWAY 248 | ||||||||
| Address2: | STE, 202 | ||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656163758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173357000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1150 STATE HIGHWAY 248 | ||||||||
| Address2: | STE, 202 | ||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656163758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173357000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R3E69 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080110697 | 01 | RAILROAD MEDICARE | OTHER | 202071965 | 05 | MO | MEDICAID | 1667 | 01 | COX HEALTH SYSTEMS | OTHER | 8068 | 01 | BCBS | OTHER | P00237019 | 01 | RAILROAD MEDICARE | OTHER | 1107752 | 01 | HEALTHLINK | OTHER |