Provider Demographics
NPI:1558342725
Name:BLASS, MARCUS (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:BLASS
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 1:551 LINN ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:269-686-5850
Practice Address - Fax:269-686-5897
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI036710208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI17-30505OtherPHP PROVIDER #
MI1833840OtherUNITED HEALTHCARE
MI21926OtherHEALTH PLAN OF MI
MIMB036710OtherSTATE LICENSE #
MI0200302138OtherBCBS MI PROVIDER #
MI2309OtherCOMMUNITY CHOICE MI
MIP52808OtherBLUE CARE NETWORK PROV #
MI2632169Medicaid
MI2632169Medicaid
MIZ36002008Medicare ID - Type Unspecified
MIP39040010Medicare PIN