Healthcare Provider Details

I. General information

NPI: 1952304560
Provider Name (Legal Business Name): ROBERT EDWARD MARSICO SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5783 WOOSTER PIKE
MEDINA OH
44256-8816
US

IV. Provider business mailing address

5783 WOOSTER PIKE
MEDINA OH
44256-8816
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-0569
  • Fax: 330-662-0258
Mailing address:
  • Phone: 330-725-0569
  • Fax: 330-662-0258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number35.025085
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.025085
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: