1205030574 NPI number — HOLLY NELSON MARSHALL M.D.

Table of content: HOLLY NELSON MARSHALL M.D. (NPI 1205030574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205030574 NPI number — HOLLY NELSON MARSHALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
HOLLY
Provider Middle Name:
NELSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NELSON
Provider Other First Name:
HOLLY
Provider Other Middle Name:
REID
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205030574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6569 CROSS CREEK TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRECKSVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44141-3138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-844-8140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  57007596 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 35-093511 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2949804 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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