MEDICARE: MARILENA C ORAVITAN MD

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	116	ZZ
2	207R00000X	Internal Medicine Physician	4301089425	MI

General Provider Information

NPI Number	:	1891752168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILENA C ORAVITAN MD

Provider Business Mailing Address
First Line	:	1310 WISCONSIN ST STE 101
Second Line	:
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417-2472
Country	:	US
Telephone Number	:	616-296-1600
Fax Number	:	616-296-1602

Provider Business Practice Location Address
First Line	:	1310 WISCONSIN ST
Second Line	:	SUITE 100
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417-2472
Country	:	US
Telephone Number	:	616-844-4701
Fax Number	:	616-847-1863

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	01/31/2022

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Directions to “ MARILENA C ORAVITAN MD” Practice Location

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