Basic Information
| Provider Information | |||||||||
| NPI: | 1013116672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEERSCHAERT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CARMEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEERSCHAERT | ||||||||
| OtherFirstName: | M. | ||||||||
| OtherMiddleName: | CARMEN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5135 S PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178875922 | ||||||||
| FaxNumber: | 5178875982 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488541387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172440120 | ||||||||
| FaxNumber: | 5172440163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301048363 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1013116672 | 05 | MI | MEDICAID |