Provider Demographics
NPI:1033420054
Name:BURRELL, MARC A (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:BURRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:ANTHONY
Other - Last Name:BURRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 73975
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:W231N1440 CORPORATE CT
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1303
Practice Address - Country:US
Practice Address - Phone:262-896-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67253-202085R0204X, 2085R0204X
TXP01762085R0202X
NE304332085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000089397Medicaid