MEDICARE: DR. MARK W LAY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	236771	NY
2	207Q00000X	Family Medicine Physician	31145	WI
3	207Q00000X	Family Medicine Physician	4301073557	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LM073557	OTHER	MI	BCBS IND BILLING #
2	0803810311	OTHER	MI	BCBS IND PIN #

General Provider Information

NPI Number	:	1003803313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK W LAY M.D.

Provider Business Mailing Address
First Line	:	117 S BROADWAY ST
Second Line	:
City	:	CASSOPOLIS
State	:	MI
Zip	:	49031-1242
Country	:	US
Telephone Number	:	269-445-0771
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 S BROADWAY ST
Second Line	:
City	:	CASSOPOLIS
State	:	MI
Zip	:	49031-1242
Country	:	US
Telephone Number	:	269-445-0771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. MARK W LAY M.D.” Practice Location

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