Provider Demographics
NPI:1700346764
Name:BREIDENBAUGH, MARC PHILIP (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:PHILIP
Last Name:BREIDENBAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9920 INDEPENDENCE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1487
Mailing Address - Country:US
Mailing Address - Phone:804-726-5141
Mailing Address - Fax:804-288-3150
Practice Address - Street 1:9920 INDEPENDENCE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1487
Practice Address - Country:US
Practice Address - Phone:804-285-7420
Practice Address - Fax:804-285-7454
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101274577208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101274577OtherVA LICENSE