Basic Information
| Provider Information | |||||||||
| NPI: | 1861096430 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARVEL PATH PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 260023 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631268023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104767472 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15211 VANOWEN ST STE 208 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914053623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187826600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2020 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEGMANN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104767472 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.