Healthcare Provider Details

I. General information

NPI: 1891787909
Provider Name (Legal Business Name): MARCUS ALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD SUITE 2A
LIVERPOOL NY
13088-3807
US

IV. Provider business mailing address

4567 CROSSROADS PARK DR 2ND FLOOR
LIVERPOOL NY
13088-3589
US

V. Phone/Fax

Practice location:
  • Phone: 315-452-2555
  • Fax: 315-452-2559
Mailing address:
  • Phone: 315-295-2100
  • Fax: 315-295-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number157868
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: