Healthcare Provider Details

I. General information

NPI: 1982188280
Provider Name (Legal Business Name): MARCUS A. HAYDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 RIDGE AVE
YOUNGSTOWN OH
44502
US

IV. Provider business mailing address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

V. Phone/Fax

Practice location:
  • Phone: 330-743-2192
  • Fax:
Mailing address:
  • Phone: 330-797-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.170639
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: