Provider Demographics
NPI:1699720144
Name:MARCOTTE, GARY A (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:MARCOTTE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15900 W 101ST AVE
Mailing Address - Street 2:MARCOTTE MEDICAL GROUP, SC
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311
Mailing Address - Country:US
Mailing Address - Phone:219-365-6333
Mailing Address - Fax:219-365-8291
Practice Address - Street 1:15900 W 101ST AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311
Practice Address - Country:US
Practice Address - Phone:219-365-6333
Practice Address - Fax:219-365-8291
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000603A207Q00000X
IL036057151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200211720AMedicaid
IL9930277OtherBCBS
IL036057151OtherILLINOIS PUBLIC AID
INP00310539OtherRAILROAD
IL036057151Medicaid
IN000000388132OtherANTHEM
IL080191174OtherRAILROAD
IN200760BMedicare PIN
IL203367Medicare PIN
INP00310539OtherRAILROAD
IN200211720AMedicaid
ILL94702Medicare PIN
IL215996Medicare PIN
IL036057151OtherILLINOIS PUBLIC AID
IL036057151Medicaid