Provider Demographics
NPI:1518971654
Name:ANTONISHEN, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:ANTONISHEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:231-346-6800
Mailing Address - Fax:989-340-1214
Practice Address - Street 1:223 N PARK ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1220
Practice Address - Country:US
Practice Address - Phone:231-582-8010
Practice Address - Fax:231-582-5338
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2024-02-02
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Provider Licenses
StateLicense IDTaxonomies
MI4301046169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMA046169OtherBS STATE LIC#
MI104102303Medicaid
MI1102408031OtherBCBSM PIN
MI23D0963677OtherCLIA
MI1102408031OtherBCBSM PIN
MIA79880Medicare UPIN