Provider Demographics
NPI:1497786990
Name:BABCOCK, MARK J (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BABCOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:J
Other - Last Name:BABCOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:4791 E WESTGATE DR BAY CITY
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2619
Mailing Address - Country:US
Mailing Address - Phone:989-493-0542
Mailing Address - Fax:
Practice Address - Street 1:8680 GRATIOT RD STE B
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48609-4885
Practice Address - Country:US
Practice Address - Phone:899-401-4791
Practice Address - Fax:899-401-4794
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4673812Medicaid
MIP00177080Medicare PIN
MIN75070003Medicare ID - Type Unspecified
MI4673812Medicaid