Basic Information
Provider Information | |||||||||
NPI: | 1659348746 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARIENCHECK | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | MEDICAL CENTER BLVD. | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271570001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367161332 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 87B MURRAY GUARD DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383053628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316641375 | ||||||||
FaxNumber: | 7316608319 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2006 | ||||||||
LastUpdateDate: | 08/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 9800627 | NC | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207N00000X | MD34201 | TN | N |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 3848074 | 05 | TN |   | MEDICAID |