Provider Demographics
NPI:1932153947
Name:MARSHALL, THOMAS R (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6820 PARKDALE PL
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6601
Practice Address - Country:US
Practice Address - Phone:317-297-7773
Practice Address - Fax:317-297-3619
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01032356A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200040630Medicaid
INM400064928Medicare PIN
IN715530HHHMedicare PIN
IN200040630Medicaid