Provider Demographics
NPI:1629013966
Name:MARCELLUS, PETER R (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:MARCELLUS
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 1:1150 STATE HIGHWAY 248
Mailing Address - Street 2:STE, 202
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3758
Mailing Address - Country:US
Mailing Address - Phone:417-335-7000
Mailing Address - Fax:
Practice Address - Street 1:1150 STATE HIGHWAY 248
Practice Address - Street 2:STE, 202
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3758
Practice Address - Country:US
Practice Address - Phone:417-335-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3E69207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080110697OtherRAILROAD MEDICARE
MO202071965Medicaid
1667OtherCOX HEALTH SYSTEMS
8068OtherBCBS
P00237019OtherRAILROAD MEDICARE
1107752OtherHEALTHLINK
8068OtherBCBS
P00237019OtherRAILROAD MEDICARE