Basic Information
| Provider Information | |||||||||
| NPI: | 1780683391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAY | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | RADIOLOGY | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833270 | ||||||||
| FaxNumber: | 2173834116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301061520 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036130848 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 104363730 | 05 | MI | MEDICAID | MH061520 | 01 | MI | BC/BS INDIVIDUAL PIN NO | OTHER | 300128669 | 01 | MI | RR MDCR INDIVIDUAL PIN NO | OTHER | 11278282 | 01 | MI | CAQH | OTHER |