Provider Demographics
NPI:1497704480
Name:HINES, MARYBETH (DO)
Entity Type:Individual
Prefix:DR
First Name:MARYBETH
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1000
Mailing Address - Fax:906-483-1103
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1000
Practice Address - Fax:906-483-1103
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI51010262207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0829560001OtherMEDICARE DME
MI0C16002OtherMEDICARE GROUP
MIMH010262OtherBLUECROSS STATE ID
MI114509440Medicaid
MI0C16002068Medicare PIN
MIMH010262OtherBLUECROSS STATE ID