Healthcare Provider Details

I. General information

NPI: 1720157688
Provider Name (Legal Business Name): MARK A PRIEST DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 E 8TH ST STE B
TRAVERSE CITY MI
49686-2895
US

IV. Provider business mailing address

6227 FRANKFORT HWY
BENZONIA MI
49616-8632
US

V. Phone/Fax

Practice location:
  • Phone: 231-922-0667
  • Fax:
Mailing address:
  • Phone: 231-882-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMP009980
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: