Healthcare Provider Details

I. General information

NPI: 1548374796
Provider Name (Legal Business Name): MARK PAULUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3847 PINE GROVE AVE SUITE B
FORT GRATIOT MI
48059-4265
US

IV. Provider business mailing address

2028 MILITARY ST
PORT HURON MI
48060-5971
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-2250
  • Fax:
Mailing address:
  • Phone: 810-931-3372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: