Healthcare Provider Details

I. General information

NPI: 1891291423
Provider Name (Legal Business Name): MARIAN FAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date: 12/12/2021
Reactivation Date: 03/22/2022

III. Provider practice location address

3569 RIDGE RD
CLEVELAND OH
44102-5443
US

IV. Provider business mailing address

PO BOX 72674
CLEVELAND OH
44192-0002
US

V. Phone/Fax

Practice location:
  • Phone: 216-281-0872
  • Fax: 216-961-5429
Mailing address:
  • Phone: 216-281-0872
  • Fax: 216-961-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA174623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: