Healthcare Provider Details

I. General information

NPI: 1437220241
Provider Name (Legal Business Name): MARY LOUISE LOUDER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY LOUISE MARK D.O.

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 11/25/2022
Certification Date: 11/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 PINEHILL DR
HOLLAND MI
49424
US

IV. Provider business mailing address

3700 52ND ST SE
GRAND RAPIDS MI
49512-9637
US

V. Phone/Fax

Practice location:
  • Phone: 616-201-8955
  • Fax: 616-656-3701
Mailing address:
  • Phone: 616-656-3700
  • Fax: 616-656-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL-1033
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCO 40167
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-008880
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMI5101012165
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003339A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: