Healthcare Provider Details

I. General information

NPI: 1164817680
Provider Name (Legal Business Name): CHARLES MARCUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE DEPT OF
ATLANTA GA
30308-2247
US

IV. Provider business mailing address

170 AMSTERDAM AVE APT 20B
NEW YORK NY
10023-5076
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-4843
  • Fax: 404-712-7435
Mailing address:
  • Phone: 443-831-7942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number84780
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number84780
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number84780
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number84780
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: