Healthcare Provider Details

I. General information

NPI: 1164405643
Provider Name (Legal Business Name): MARSHALL M. POOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S COLLEGE AVE SUITE A
BLOOMINGTON IN
47403-2500
US

IV. Provider business mailing address

700 S COLLEGE AVE SUITE A
BLOOMINGTON IN
47403-2500
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-8168
  • Fax: 812-331-1096
Mailing address:
  • Phone: 812-331-8168
  • Fax: 812-331-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01039391
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: