Provider Demographics
NPI:1619938545
Name:GOSTINE, MARK LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LOUIS
Last Name:GOSTINE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 E PARIS AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1006
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-05-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301041353208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7000027071OtherPRIORITY HEALTH
1070467OtherFIRST HEALTH
MI550410415OtherBLUE CROSS BLUE SHIELD
1492766OtherCIGNA
40982OtherAETNA
MI4552951-10Medicaid
7000027071OtherPRIORITY HEALTH MEDICAID
MI4654209-10Medicaid
MI550410415OtherBLUE CROSS BLUE SHIELD
1492766OtherCIGNA