MEDICARE: DR. MARK MCKELVY GARNER PH.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	103TC0700X	Clinical Psychologist	6301006596	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	68-0-B8-4791	OTHER	MI	BLUE CROSS BLUE SHIELD
2	M025581	OTHER	MI	CHAMPUSTRICARE
3	68-0-B8-4791	OTHER	MI	MICHIGAN BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1558438838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK MCKELVY GARNER PH.D.

Provider Business Mailing Address
First Line	:	12935 S WEST BAY SHORE DR STE 260
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-5597
Country	:	US
Telephone Number	:	231-642-1641
Fax Number	:

Provider Business Practice Location Address
First Line	:	12935 S WEST BAY SHORE DR STE 260
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-5597
Country	:	US
Telephone Number	:	231-642-1641
Fax Number	:

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	01/11/2021

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