Provider Demographics
NPI:1336119106
Name:HANNIS, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HANNIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:15101 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4611
Practice Address - Country:US
Practice Address - Phone:313-582-2769
Practice Address - Fax:313-846-7708
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301071197207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B65512Medicare UPIN