MEDICARE: PAUL S MARCUM CDCA PRELIMINARY

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1609533892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL S MARCUM CDCA PRELIMINARY

Provider Business Mailing Address
First Line	:	2461 S PATTERSON BLVD
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45409-1837
Country	:	US
Telephone Number	:	937-727-2775
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 WHITE ALLEN AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-4932
Country	:	US
Telephone Number	:	937-938-9772
Fax Number	:

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

Provider Enumeration Date	:	11/22/2021
Last Update Date	:	11/22/2021

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