Healthcare Provider Details

I. General information

NPI: 1649439472
Provider Name (Legal Business Name): MARC STUART ZELICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 PEPPERWOOD CIR SW SUITE C
HUNTSVILLE AL
35801-7437
US

IV. Provider business mailing address

PO BOX 2705 SUITE C
HUNTSVILLE AL
35804-2705
US

V. Phone/Fax

Practice location:
  • Phone: 256-882-1908
  • Fax: 256-882-1907
Mailing address:
  • Phone: 256-265-5951
  • Fax: 256-265-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32718
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: