Individual
MARIANNE NELSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
420 E MAIN ST, BROOK, IN 47922-8715
(219) 275-2521
(219) 275-9342
Mailing address
PO BOX 771923, DETROIT, MI 48278-1923
(317) 528-8000
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01033812
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001130557
ANTHEM
—
05
—
100143000
—
IN
Enumeration date
08/22/2005
Last updated
12/01/2021
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