Basic Information
| Provider Information | |||||||||
| NPI: | 1902250095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARRIOTT | ||||||||
| FirstName: | RICHARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958839 | ||||||||
| FaxNumber: | 9373958387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3525 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958839 | ||||||||
| FaxNumber: | 9373958387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.136741 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.