MEDICARE: TATJANA MARIC MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2084P0804X	Child & Adolescent Psychiatry Physician	1164712055	MI

General Provider Information

NPI Number	:	1164712055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATJANA MARIC MD

Provider Business Mailing Address
First Line	:	420 BALTIMORE DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-3934
Country	:	US
Telephone Number	:	323-633-3503
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 BALTIMORE DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-3934
Country	:	US
Telephone Number	:	323-633-3503
Fax Number	:

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

Provider Enumeration Date	:	04/12/2011
Last Update Date	:	02/15/2017

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