Provider Demographics
NPI:1790750685
Name:CRACIUM, MARY (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CRACIUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 GRATIOT BLVD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2215
Mailing Address - Country:US
Mailing Address - Phone:810-364-5050
Mailing Address - Fax:810-364-5688
Practice Address - Street 1:1985 GRATIOT BLVD
Practice Address - Street 2:SUITE 2A
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2215
Practice Address - Country:US
Practice Address - Phone:810-364-5050
Practice Address - Fax:810-364-5688
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101006996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4388505Medicaid
MI4737867Medicaid
MIA78057Medicare UPIN
MI4737867Medicaid
MI4388505Medicaid