Provider Demographics
NPI:1760462964
Name:WEIN, MARK BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRIAN
Last Name:WEIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11368 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4372
Mailing Address - Country:US
Mailing Address - Phone:734-403-2222
Mailing Address - Fax:734-403-2400
Practice Address - Street 1:11368 ALLEN RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4372
Practice Address - Country:US
Practice Address - Phone:734-403-2222
Practice Address - Fax:734-403-2400
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4517442Medicaid
MION77330001Medicare ID - Type Unspecified
MI4517442Medicaid