MEDICARE: WATTLES PARK FAMILY PRACTICE PC

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	4301083010	MI

General Provider Information

NPI Number	:	1659512705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATTLES PARK FAMILY PRACTICE PC

Provider Business Mailing Address
First Line	:	1125 MICHIGAN AVE E
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-6832
Country	:	US
Telephone Number	:	269-969-6291
Fax Number	:	269-969-6085

Provider Business Practice Location Address
First Line	:	1125 MICHIGAN AVE E
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-6832
Country	:	US
Telephone Number	:	269-969-6291
Fax Number	:	269-969-6085

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. MARK R HENRY
Credential	:	M.D.
Telephone Number	:	269-969-6291

Provider Enumeration Date	:	03/19/2009
Last Update Date	:	06/09/2009

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