Provider Demographics
NPI:1477607638
Name:PARK, PIERCE C (MD)
Entity Type:Individual
Prefix:
First Name:PIERCE
Middle Name:C
Last Name:PARK
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 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 344
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
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:SUITE 344
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3910
Practice Address - Fax:906-225-4529
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-092802207RN0300X
MI4301103759207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2949153Medicaid
OH2949153Medicaid