=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447313119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER J. MARCUS D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 09/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2710 E OAKLAND PARK BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33306-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-575-1175
-----------------------------------------------------
Fax | 954-566-0361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2710 E OAKLAND PARK BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33306-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-575-1175
-----------------------------------------------------
Fax | 954-566-0361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH7508
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------