Basic Information
| Provider Information | |||||||||
| NPI: | 1225610686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARNEY | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 BYRON AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480712046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489537461 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865737470 | ||||||||
| FaxNumber: | 5865730850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 20004022 | 01 | RESIDENT | OTHER |