Healthcare Provider Details

I. General information

NPI: 1124002738
Provider Name (Legal Business Name): STEPHANIE D MARSHALL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8684 CONNECTICUT ST STE A
MERRILLVILLE IN
46410-5581
US

IV. Provider business mailing address

8684 CONNECTICUT ST STE A
MERRILLVILLE IN
46410-5581
US

V. Phone/Fax

Practice location:
  • Phone: 192-472-8990
  • Fax: 219-472-0270
Mailing address:
  • Phone: 192-472-8990
  • Fax: 219-472-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036-099475
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number02001947A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number02001947A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: