Provider Demographics
NPI:1053381871
Name:MCELROY, MARVIN EARL (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:EARL
Last Name:MCELROY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1064 W WEST BRANCH RD
Mailing Address - Street 2:PO BOX 268
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651
Mailing Address - Country:US
Mailing Address - Phone:989-366-4800
Mailing Address - Fax:989-366-4832
Practice Address - Street 1:1064 W WEST BRANCH RD
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651
Practice Address - Country:US
Practice Address - Phone:989-366-4800
Practice Address - Fax:989-366-4832
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301403219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2934910Medicaid
MI072988OtherBLUE CROSS
MI0722988Medicare ID - Type Unspecified
MI2934910Medicaid