Basic Information
| Provider Information | |||||||||
| NPI: | 1184680563 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIETTA CRITICAL CARE ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 713203 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432710001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006552656 | ||||||||
| FaxNumber: | 4128227411 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 18TH ST | ||||||||
| Address2: | STE 131 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044244680 | ||||||||
| FaxNumber: | 3044244773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | GILBERT | ||||||||
| AuthorizedOfficialFirstName: | TERRENCE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3044244680 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 211020 | 01 | OH | BCBS | OTHER | CH5486 | 01 | OH | RAILROAD MEDICARE | OTHER | 0208846000 | 05 | WV | MEDICAID | 2257507 | 05 | OH | MEDICAID |