MEDICARE: KEITH A. MARCUS, MD INC.

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	261QM2500X	Medical Specialty Clinic/Center	A102230	CA

General Provider Information

NPI Number	:	1952552416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH A. MARCUS, MD INC.

Provider Business Mailing Address
First Line	:	1815 VIA EL PRADO
Second Line	:	SUITE 102
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5722
Country	:	US
Telephone Number	:	310-544-5010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 VIA EL PRADO
Second Line	:	SUITE 102
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5722
Country	:	US
Telephone Number	:	310-544-5010
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. KEITH ALAN MARCUS
Credential	:	M.D.
Telephone Number	:	310-544-5010

Provider Enumeration Date	:	10/02/2008
Last Update Date	:	10/02/2008

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