MEDICARE: CHARLES LEE MARCUM M.D.

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	207P00000X	Emergency Medicine Physician	28918	KY

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
2	000000053343	OTHER	KY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1750337440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES LEE MARCUM M.D.

Provider Business Mailing Address
First Line	:	284 ROSE HILL AVE
Second Line	:
City	:	VERSAILLES
State	:	KY
Zip	:	40383-1224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 TRILLIUM WAY
Second Line	:
City	:	CORBIN
State	:	KY
Zip	:	40701-8426
Country	:	US
Telephone Number	:	606-528-1212
Fax Number	:

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	07/08/2007

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