Provider Demographics
NPI:1861681819
Name:MARK C. ANTONISHEN, M.D., P.L.L.C.
Entity Type:Organization
Organization Name:MARK C. ANTONISHEN, M.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANTONISHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-6030
Mailing Address - Street 1:405 N DIVISION RD
Mailing Address - Street 2:STE 3
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9045
Mailing Address - Country:US
Mailing Address - Phone:231-487-6030
Mailing Address - Fax:231-487-6010
Practice Address - Street 1:405 N DIVISION RD
Practice Address - Street 2:STE 3
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9045
Practice Address - Country:US
Practice Address - Phone:231-487-6030
Practice Address - Fax:231-487-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P16400Medicare PIN