Basic Information
Provider Information | |||||||||
NPI: | 1356509947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PANKONIN | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | STEVEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D./PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1447 N HARRISON ST | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486024727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895832833 | ||||||||
FaxNumber: | 9895831440 | ||||||||
Practice Location | |||||||||
Address1: | 900 COOPER AVE | ||||||||
Address2: | SUITE 4300 | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486025182 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895837460 | ||||||||
FaxNumber: | 9895837432 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2008 | ||||||||
LastUpdateDate: | 10/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 2021-02901 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 4301105873 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.