MEDICARE: DR. MARK ALLEN MENESTRINA 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	207QA0401X	Addiction Medicine (Family Medicine) Physician	045529	MI

General Provider Information

NPI Number	:	1265498059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ALLEN MENESTRINA MD

Provider Business Mailing Address
First Line	:	17351 INKSTER RD
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48152
Country	:	US
Telephone Number	:	734-421-7997
Fax Number	:

Provider Business Practice Location Address
First Line	:	12851 E GRAND RIVER
Second Line	:	BRIGHTON HOSPITAL
City	:	BRIGHTON
State	:	MI
Zip	:	48116-8596
Country	:	US
Telephone Number	:	810-227-1211
Fax Number	:	810-227-6893

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

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	07/08/2007

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