Provider Demographics
NPI:1003890187
Name:MACKEY, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MACKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4158 SOUTHMOOR LN
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-3127
Mailing Address - Country:US
Mailing Address - Phone:248-626-1874
Mailing Address - Fax:
Practice Address - Street 1:6621 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3004
Practice Address - Country:US
Practice Address - Phone:248-661-4700
Practice Address - Fax:248-661-6210
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMM059872207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3410648-10Medicaid
MI3410648-10Medicaid
MIG48840Medicare UPIN