Basic Information
| Provider Information | |||||||||
| NPI: | 1811070949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIMMERER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | 6163615828 | ||||||||
| Practice Location | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | 6163615828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 05/08/2009 | ||||||||
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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 | 2085R0202X | 4301406940 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300023174 | 01 | MI | RAILROAD MEDICARE | OTHER | 300023192 | 01 | MI | RAILROAD MEDICARE | OTHER | 2829389 | 05 | MI | MEDICAID | 2824810 | 05 | MI | MEDICAID | 200000001748 | 01 | MI | PHP OF MIDMICHIGAN | OTHER | 2832974 | 05 | MI | MEDICAID |