Healthcare Provider Details

I. General information

NPI: 1730185273
Provider Name (Legal Business Name): MARC S KRAKOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S CORAL ST
KALKASKA MI
49646-2503
US

IV. Provider business mailing address

1105 6TH ST
TRAVERSE CITY MI
49684-2349
US

V. Phone/Fax

Practice location:
  • Phone: 231-258-7506
  • Fax: 231-258-7592
Mailing address:
  • Phone: 231-947-0673
  • Fax: 801-740-2847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301059989
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: