Basic Information
| Provider Information | |||||||||
| NPI: | 1649244286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9398 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342540453 | ||||||||
| FaxNumber: | 7344591855 | ||||||||
| Practice Location | |||||||||
| Address1: | 9398 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342540453 | ||||||||
| FaxNumber: | 7344591855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009615 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 5101009615 | MI | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1649244286 | 05 | MI | MEDICAID |