Provider Demographics
NPI:1285850784
Name:MARIASH, EVAN (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:MARIASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2969
Mailing Address - Country:US
Mailing Address - Phone:763-581-2801
Mailing Address - Fax:
Practice Address - Street 1:3435 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2969
Practice Address - Country:US
Practice Address - Phone:763-581-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD13676207R00000X
RILP00959208M00000X
390200000X
MN59748207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI002186601OtherMEDICARE
RI1285850784OtherBCBS/BLUE CHIP
RIEM85188Medicaid