Provider Demographics
NPI:1740243369
Name:STID, MARK ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:STID
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:904 S WASHINGTON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-8035
Mailing Address - Fax:616-392-7404
Practice Address - Street 1:904 S WASHINGTON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-392-8035
Practice Address - Fax:616-392-7404
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMS055336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3164034 10Medicaid
MIOM13670Medicare ID - Type Unspecified
MIG13993Medicare UPIN