Provider Demographics
NPI:1164462354
Name:HENRY, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:HENRY
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 1:1125 MICHIGAN AVE E
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-6832
Mailing Address - Country:US
Mailing Address - Phone:269-969-6014
Mailing Address - Fax:269-969-6085
Practice Address - Street 1:1125 MICHIGAN AVE E
Practice Address - Street 2:SUITE 5
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-6832
Practice Address - Country:US
Practice Address - Phone:269-969-6014
Practice Address - Fax:269-969-6085
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI054271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4227999Medicaid
MI0M98600010Medicare PIN
MI4227999Medicaid
MIN25600001Medicare PIN