Provider Demographics
NPI:1730299074
Name:GREENWELL, MARK G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:GREENWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:526 W GENESEE ST
Mailing Address - Street 2:UNIT #3
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1701
Mailing Address - Country:US
Mailing Address - Phone:989-652-7344
Mailing Address - Fax:989-652-7355
Practice Address - Street 1:526 W GENESEE ST
Practice Address - Street 2:UNIT #3
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1701
Practice Address - Country:US
Practice Address - Phone:989-652-7344
Practice Address - Fax:989-652-7355
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMG4301070378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0007540068OtherAETNA
080730251OtherBCBS
0N52460Medicare ID - Type Unspecified
080730251OtherBCBS