Provider Demographics
NPI:1700996576
Name:PHILIP M MARDEN MD SC
Entity type:Organization
Organization Name:PHILIP M MARDEN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:MARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-667-0366
Mailing Address - Street 1:340 SUMMIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3747
Mailing Address - Country:US
Mailing Address - Phone:262-567-0366
Mailing Address - Fax:262-567-0368
Practice Address - Street 1:340 SUMMIT AVENUE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3747
Practice Address - Country:US
Practice Address - Phone:262-567-0366
Practice Address - Fax:262-567-0368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14664207KA0200X, 207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS68366510001OtherCIGNA
112760524654OtherHUMANA
WI31212300Medicaid
718112OtherMANAGED HEALTH SERVICES
14664OtherMEDICAL LICENSE
1200110OtherUNITED HEALTH CARE
52D0388538OtherCLIA CERTIFICATE
1000283OtherPHYSICIANS PLUS INSURANCE
12659OtherDEAN HEALTH PLAN
213688OtherONE HEALTH PLAN
4308968OtherAETNA
W003437OtherCHAMPUS
MARDENPHIOtherMERCYCARE HEALTH PLANS
AS68366510001OtherCIGNA
MARDENPHIOtherMERCYCARE HEALTH PLANS
WI31212300Medicaid
MARDENPHIOtherMERCYCARE HEALTH PLANS