MEDICARE: DR. BASIL JOHN MARRELLA DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	5101006788	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407833270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BASIL JOHN MARRELLA DO

Provider Business Mailing Address
First Line	:	30855 JOHN R RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-5213
Country	:	US
Telephone Number	:	248-583-0100
Fax Number	:	248-583-4894

Provider Business Practice Location Address
First Line	:	30855 JOHN R RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-5213
Country	:	US
Telephone Number	:	248-583-0100
Fax Number	:	248-583-4894

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	12/28/2011

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