Healthcare Provider Details

I. General information

NPI: 1710494976
Provider Name (Legal Business Name): MARSHAL THOMAS HYDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GREENLAWN AVE # 200
LANSING MI
48910-2898
US

IV. Provider business mailing address

3503 AUTUMNWOOD LN
OKEMOS MI
48864-5995
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 517-898-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: