Basic Information
| Provider Information | |||||||||
| NPI: | 1053054106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCUM | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 BROOKS RANGE LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253091150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044444335 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043885432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2022 | ||||||||
| LastUpdateDate: | 04/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.