Provider Demographics
NPI:1073775599
Name:MARKOVICH, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MARKOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 111
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1116
Mailing Address - Country:US
Mailing Address - Phone:586-779-7610
Mailing Address - Fax:586-445-2523
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:STE 111
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:586-445-2523
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000439237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E06192OtherBLUE SHIELD
MI0E01107OtherBLUE SHIELD
MI0E01107OtherBLUE SHIELD