Provider Demographics
NPI:1063088698
Name:CRUM, MARLON D
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:D
Last Name:CRUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-2874
Mailing Address - Country:US
Mailing Address - Phone:440-444-4226
Mailing Address - Fax:
Practice Address - Street 1:120 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2874
Practice Address - Country:US
Practice Address - Phone:440-444-4226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRZ574107172A00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver