Provider Demographics
NPI:1710911557
Name:CUNDIFF, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CUNDIFF
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:PO BOX 681
Mailing Address - Street 2:
Mailing Address - City:GLEN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5915 RAY ST. M22, UNIT #5
Practice Address - Street 2:
Practice Address - City:GLEN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:49636
Practice Address - Country:US
Practice Address - Phone:231-334-0008
Practice Address - Fax:231-334-0108
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMC011558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON95800Medicare ID - Type Unspecified