Healthcare Provider Details

I. General information

NPI: 1598704652
Provider Name (Legal Business Name): MARK H TUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 SCHAEFER RD
DEARBORN MI
48126-3249
US

IV. Provider business mailing address

143 FOREST GLEN DR
HOLLAND OH
43528-9207
US

V. Phone/Fax

Practice location:
  • Phone: 313-581-2600
  • Fax: 313-581-0228
Mailing address:
  • Phone: 419-861-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301037522
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: