Healthcare Provider Details

I. General information

NPI: 1962820829
Provider Name (Legal Business Name): MARISSA L BAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

V. Phone/Fax

Practice location:
  • Phone: 513-246-2300
  • Fax: 513-245-5424
Mailing address:
  • Phone: 513-246-2300
  • Fax: 513-245-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003974
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: