Provider Demographics
NPI:1154437382
Name:FAVALI, MARCIA L (MD)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:L
Last Name:FAVALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3120
Mailing Address - Fax:812-242-3846
Practice Address - Street 1:221 S 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4214
Practice Address - Country:US
Practice Address - Phone:812-242-3120
Practice Address - Fax:812-242-3846
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033320A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100251840Medicaid
000000089614OtherANTHEM
INP00834918OtherRAILROAD MEDICARE
080011074OtherRAILROAD MCARE PALAMETTO
IN192770BBMedicare PIN
080011074OtherRAILROAD MCARE PALAMETTO
IN265130RMedicare PIN
IN859910MMedicare PIN