Healthcare Provider Details

I. General information

NPI: 1740397355
Provider Name (Legal Business Name): MARLON L HERMITANIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8100
  • Fax:
Mailing address:
  • Phone: 920-288-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36685
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-098039
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number36685
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: