Provider Demographics
NPI:1831137629
Name:MARK, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:MARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 2000
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-391-2192
Practice Address - Fax:616-391-3114
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040767A207V00000X
MI4301057958207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831137629Medicaid
IN200056530AMedicaid
MI0D16228049Medicare PIN
MIM74460711Medicare PIN
IN735850JMedicare ID - Type Unspecified
IN200056530AMedicaid