MEDICARE: DR. MARK R HENRY M.D.

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	207Q00000X	Family Medicine Physician	054271	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164462354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK R HENRY M.D.

Provider Business Mailing Address
First Line	:	1125 MICHIGAN AVE E
Second Line	:	SUITE 5
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-6832
Country	:	US
Telephone Number	:	269-969-6014
Fax Number	:	269-969-6085

Provider Business Practice Location Address
First Line	:	1125 MICHIGAN AVE E
Second Line	:	SUITE 5
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-6832
Country	:	US
Telephone Number	:	269-969-6014
Fax Number	:	269-969-6085

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	04/29/2008

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