Healthcare Provider Details

I. General information

NPI: 1275741274
Provider Name (Legal Business Name): MARK A MARINELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

401 N 12TH ST. PO BOX 980530
RICHMOND VA
23298-0530
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-4080
  • Fax:
Mailing address:
  • Phone: 804-828-4080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101238976
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: