Provider Demographics
NPI:1689731119
Name:STANSBERRY, MARK T (PT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:STANSBERRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2242
Mailing Address - Country:US
Mailing Address - Phone:989-779-2920
Mailing Address - Fax:989-772-9424
Practice Address - Street 1:1106 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2242
Practice Address - Country:US
Practice Address - Phone:989-779-2920
Practice Address - Fax:989-772-9424
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI352191234OtherPPOM PROVIDER NUMBER
MI650C700040OtherBCBSM PROVIDER NUMBER
MI0N63410001Medicare ID - Type UnspecifiedPROVIDER GROUP NUMBER