Basic Information
| Provider Information | |||||||||
| NPI: | 1841266806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | RICHARD CONNELY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | MCLAREN PORT HURON - EMERGENCY MEDICINE DEPARTMENT | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109893300 | ||||||||
| FaxNumber: | 8109852671 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | MCLAREN PORT HURON - EMERGENCY MEDICINE DEPARTMENT | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109893300 | ||||||||
| FaxNumber: | 8109852671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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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 | 207P00000X | 5101014908 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1841266806 | 05 | MI | MEDICAID |