Healthcare Provider Details

I. General information

NPI: 1265592745
Provider Name (Legal Business Name): S S MARATHE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WEST LATTIN STREET
HASTINGS FL
32145
US

IV. Provider business mailing address

665 STATE ROAD 207 SUITE 102
SAINT AUGUSTINE FL
32084-5938
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8158
  • Fax: 904-823-1284
Mailing address:
  • Phone: 904-824-8158
  • Fax: 904-823-1284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94907
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number91451
License Number StateFL

VIII. Authorized Official

Name: SHRIRAM S MARATHE
Title or Position: PRESIDENT
Credential: MD
Phone: 904-824-8158