Provider Demographics
NPI:1750483426
Name:TRUDELL, MARK G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:TRUDELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2070 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5108
Mailing Address - Country:US
Mailing Address - Phone:810-695-5353
Mailing Address - Fax:810-695-0616
Practice Address - Street 1:2070 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5108
Practice Address - Country:US
Practice Address - Phone:810-695-5353
Practice Address - Fax:810-695-0616
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301046553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3235931Medicaid
MIB43442Medicare UPIN
MIM23560052Medicare PIN