MEDICARE: ROBERT MARRIOTT MEDICAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518418128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT MARRIOTT MEDICAL CORP

Provider Business Mailing Address
First Line	:	222 N PACIFIC COAST HWY STE 2175
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-5639
Country	:	US
Telephone Number	:	877-878-3289
Fax Number	:	877-817-3227

Provider Business Practice Location Address
First Line	:	4900 E BERRY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-4314
Country	:	US
Telephone Number	:	877-878-3289
Fax Number	:	877-817-3227

Authorized Official
Title or Position	:	CEO
Name	:	ROBERT J MARRIOTT
Credential	:	MD
Telephone Number	:	877-878-3289

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	11/08/2018

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