Provider Demographics
NPI:1679775654
Name:MARCUM, MICHAEL BRYANT
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRYANT
Last Name:MARCUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 MORRIS LANE BLUE RUN RD # A
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8701
Mailing Address - Country:US
Mailing Address - Phone:740-259-9531
Mailing Address - Fax:740-259-9531
Practice Address - Street 1:1465 MORRIS LANE BLUE RUN RD # A
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8701
Practice Address - Country:US
Practice Address - Phone:740-259-9531
Practice Address - Fax:740-259-9531
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHVL73038714171WH0202X
OH2229743332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171WH0202XOther Service ProvidersContractorHome Modifications
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2229743Medicaid