Healthcare Provider Details

I. General information

NPI: 1790351138
Provider Name (Legal Business Name): MICHAEL L MARCUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 EDWARDS ST
ALTON IL
62002-3915
US

IV. Provider business mailing address

902 W MAIN ST
WEST FRANKFORT IL
62896-2210
US

V. Phone/Fax

Practice location:
  • Phone: 618-462-2331
  • Fax: 618-462-2504
Mailing address:
  • Phone: 618-937-6483
  • Fax: 618-937-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: