Provider Demographics
NPI:1316983273
Name:CITY OF MARIETTA
Entity type:Organization
Organization Name:CITY OF MARIETTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH COMMISSIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-373-0611
Mailing Address - Street 1:304 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3022
Mailing Address - Country:US
Mailing Address - Phone:740-373-0611
Mailing Address - Fax:740-376-2008
Practice Address - Street 1:304 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3022
Practice Address - Country:US
Practice Address - Phone:740-373-0611
Practice Address - Fax:740-376-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043094B251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0515071Medicaid
OH0515071Medicaid