Provider Demographics
NPI:1548373392
Name:MARSHALL, BRUCE ALLEN (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:MARSHALL
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 1:6450 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686
Mailing Address - Country:US
Mailing Address - Phone:217-788-3000
Mailing Address - Fax:217-788-5577
Practice Address - Street 1:101 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-622-4693
Practice Address - Fax:217-788-5556
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102654207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL011112OtherHEALTH ALLIANCE
IL036102654Medicaid
IL220028805OtherRR MEDICARE
IL32017OtherPERSONAL CARE ID
IL020102500OtherBLACK LUNG
IL08415043OtherIL BLUE CROSS BLUE SHIELD
IL684895OtherHEALTHLINK
ILC12333OtherRR MEDICARE GROUP
IL133101600OtherACS
IL14D0435736OtherCLIA