Healthcare Provider Details

I. General information

NPI: 1194034884
Provider Name (Legal Business Name): RALPH G. MARINO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 CLYDE MORRIS BLVD SUITE 200
ORMOND BEACH FL
32174-8181
US

IV. Provider business mailing address

305 CLYDE MORRIS BLVD SUITE 200
ORMOND BEACH FL
32174-8181
US

V. Phone/Fax

Practice location:
  • Phone: 386-492-2914
  • Fax: 386-492-7832
Mailing address:
  • Phone: 386-492-2914
  • Fax: 386-492-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME22860
License Number StateFL

VIII. Authorized Official

Name: MRS. ELLEN R HOLM
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-492-2914