Basic Information
| Provider Information | |||||||||
| NPI: | 1518971654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTONISHEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10850 E TRAVERSE HWY | ||||||||
| Address2: | SUITE 4400 | ||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496841364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313466800 | ||||||||
| FaxNumber: | 9893401214 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 N PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOYNE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497121220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315828010 | ||||||||
| FaxNumber: | 2315825338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301046169 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 23D0963677 | 01 | MI | CLIA | OTHER | 104102303 | 05 | MI | MEDICAID | 1102408031 | 01 | MI | BCBSM PIN | OTHER | MA046169 | 01 | MI | BS STATE LIC# | OTHER |