Basic Information
| Provider Information | |||||||||
| NPI: | 1417259680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARION INDEPENDENT PHYSICIANS ASSOCIATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1167 INDEPENDENCE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026360 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1069 DELAWARE AVE | ||||||||
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| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433021400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403874578 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2010 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | HEMPSTEAD | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7403877200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2104127 | 05 | OH | MEDICAID |