Healthcare Provider Details

I. General information

NPI: 1548373186
Provider Name (Legal Business Name): MARILYN EILEEN CONLON M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 WAYNE ST
TRAVERSE CITY MI
49684-1432
US

IV. Provider business mailing address

2400 NORTHERN VISIONS DR
TRAVERSE CITY MI
49684-7034
US

V. Phone/Fax

Practice location:
  • Phone: 231-995-0959
  • Fax:
Mailing address:
  • Phone: 231-922-9625
  • Fax: 231-929-5594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMC072857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: