Provider Demographics
NPI:1003803313
Name:LAY, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:LAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-1242
Mailing Address - Country:US
Mailing Address - Phone:269-445-0771
Mailing Address - Fax:
Practice Address - Street 1:117 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1242
Practice Address - Country:US
Practice Address - Phone:269-445-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236771207Q00000X
WI31145207Q00000X
MI4301073557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILM073557OtherBCBS IND BILLING #
MI0803810311OtherBCBS IND PIN #
MILM073557OtherBCBS IND BILLING #