Provider Demographics
NPI:1063743250
Name:MARSHALL, MARILYN RADCLIFFE
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:RADCLIFFE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8913
Mailing Address - Fax:240-439-8910
Practice Address - Street 1:504 E RIDGEVILLE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771
Practice Address - Country:US
Practice Address - Phone:240-215-6370
Practice Address - Fax:240-439-8910
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant