Provider Demographics
NPI:1033164744
Name:JOSEPH, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JOSEPH
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-8050
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:STE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-685-3200
Practice Address - Fax:616-458-3526
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4609052Medicaid
MI4609043Medicaid
MI2994945Medicaid
MI3506918Medicaid
MI4878435Medicaid
MI4609034Medicaid
MI4878435Medicaid
MIP32930130Medicare ID - Type Unspecified
MI3506918Medicaid
MIM69390035Medicare ID - Type Unspecified