Healthcare Provider Details

I. General information

NPI: 1356883771
Provider Name (Legal Business Name): MARATHON HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2694 JUDGE FRAN JAMIESON WAY C/O BREVARD WELLCARE- CENTRAL
MELBOURNE FL
32940
US

IV. Provider business mailing address

20 WINOOSKI FALLS WAY STE 400
WINOOSKI VT
05404-2239
US

V. Phone/Fax

Practice location:
  • Phone: 321-252-1169
  • Fax: 321-989-0316
Mailing address:
  • Phone: 802-857-0400
  • Fax: 802-419-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY FORD
Title or Position: CEO
Credential:
Phone: 802-857-0400