MEDICARE: MRS. PENNIE MARIE MARKO CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	4704266251	MI
2	367500000X	Certified Registered Nurse Anesthetist	4704266251	MI

General Provider Information

NPI Number	:	1043556442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PENNIE MARIE MARKO CRNA

Provider Business Mailing Address
First Line	:	2025 HUNT CLUB DR
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-1703
Country	:	US
Telephone Number	:	586-292-2943
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 HUNT CLUB DR
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-1703
Country	:	US
Telephone Number	:	586-292-2943
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2012
Last Update Date	:	06/05/2014

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