Provider Demographics
NPI:1871627729
Name:RIOLAN MARBUN
Entity type:Organization
Organization Name:RIOLAN MARBUN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:RIOLAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARBUN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:252-985-1371
Mailing Address - Street 1:PO BOX 7756
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0756
Mailing Address - Country:US
Mailing Address - Phone:252-985-1371
Mailing Address - Fax:
Practice Address - Street 1:800 BRENT GLEN PT
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-7200
Practice Address - Country:US
Practice Address - Phone:615-604-6101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN35900201Medicaid
TN35900202OtherMEDICAID GROUP #
TN4146608OtherBCBS PROVIDER #
TN4146608OtherTENNCARE SELECT PROV #
TN35900202OtherMEDICARE GROUP #
TN35900201Medicare PIN
TN35900202OtherMEDICAID GROUP #