Provider Demographics
NPI:1346207974
Name:MACKERSIE, ANDREW BLAINE (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:BLAINE
Last Name:MACKERSIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-351-4905
Practice Address - Fax:517-351-4820
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01053750A2085R0202X
MI43010866902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I48234Medicare UPIN
MI0C36350070Medicare PIN
MIOC36027036Medicare PIN