=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740541663
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT T. MARSHALL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2012
-----------------------------------------------------
Last Update Date | 07/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 NICOLLS RD HSC, LEVEL 4, ROOM 080
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794-8350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-444-2478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1554
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-0988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 283170
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 283170
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 261154
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------