Provider Demographics
NPI:1902893183
Name:MARRIOTT, KENNETH ARMISTICE III (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ARMISTICE
Last Name:MARRIOTT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:215 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1533
Mailing Address - Country:US
Mailing Address - Phone:618-256-7595
Mailing Address - Fax:618-256-7575
Practice Address - Street 1:375TH MEDICAL GROUP
Practice Address - Street 2:310 W LOSEY
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-256-7595
Practice Address - Fax:618-256-7575
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236229207P00000X
TXN8121207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB144438Medicare PIN
ILOTH000Medicare UPIN