Provider Demographics
NPI:1326022013
Name:HIMES, JON MARC (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MARC
Last Name:HIMES
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 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-3910
Mailing Address - Fax:906-225-4529
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:STE 344
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3910
Practice Address - Fax:906-225-4529
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI040869207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3138357Medicaid
MI381358036011OtherTRICARE
MI110030843OtherRAILROAD MEDICARE
MI4894386Medicaid
MI0M03300001Medicare PIN
MI3138357Medicaid