Provider Demographics
NPI:1619927688
Name:ZIMMER, MARK J (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:ZIMMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2272
Mailing Address - Country:US
Mailing Address - Phone:231-922-0233
Mailing Address - Fax:989-356-4199
Practice Address - Street 1:620 2ND ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2272
Practice Address - Country:US
Practice Address - Phone:231-922-0233
Practice Address - Fax:989-356-4199
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950B85020OtherBLUE CROSS BLUE SHIELD
MIP65677OtherRAILROAD MEDICARE
MIP65677OtherRAILROAD MEDICARE
MI0M77080Medicare ID - Type Unspecified