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NPI Code Detail

MEDICARE: MARK C ANTONISHEN M.D.

MEDICARE: MARK C ANTONISHEN 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
1207R00000XInternal Medicine Physician4301046169MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MA046169OTHERMIBS STATE LIC#
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
31102408031OTHERMIBCBSM PIN
423D0963677OTHERMICLIA

General Provider Information

NPI Number : 1518971654
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK C ANTONISHEN M.D.
Provider Business Mailing Address
First Line : 10850 E TRAVERSE HWY
Second Line : SUITE 4400
City : TRAVERSE CITY
State : MI
Zip : 49684-1364
Country : US
Telephone Number : 231-346-6800
Fax Number : 989-340-1214
Provider Business Practice Location Address
First Line : 223 N PARK ST
Second Line :
City : BOYNE CITY
State : MI
Zip : 49712-1220
Country : US
Telephone Number : 231-582-8010
Fax Number : 231-582-5338
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/27/2006
Last Update Date : 02/02/2024

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Directions to “ MARK C ANTONISHEN M.D.” Practice Location

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