Provider Demographics
NPI:1497708366
Name:TRAVIS, MARC (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:TRAVIS
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:1471 E BELTLINE AVE NE
Practice Address - Street 2:STE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4548
Practice Address - Country:US
Practice Address - Phone:616-685-8620
Practice Address - Fax:616-447-7674
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4876904Medicaid
MI4624916Medicaid
MI4624925Medicaid
MI4628399Medicaid
MI4628399Medicaid
MI4624916Medicaid
MII13621Medicare UPIN
MIM02830132Medicare ID - Type Unspecified