Provider Demographics
NPI:1891752168
Name:ORAVITAN, MARILENA C (MD)
Entity Type:Individual
Prefix:
First Name:MARILENA
Middle Name:C
Last Name:ORAVITAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 WISCONSIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2472
Mailing Address - Country:US
Mailing Address - Phone:616-296-1600
Mailing Address - Fax:616-296-1602
Practice Address - Street 1:1310 WISCONSIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2472
Practice Address - Country:US
Practice Address - Phone:616-844-4701
Practice Address - Fax:616-847-1863
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ116207Q00000X
MI4301089425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080G011310OtherBCBSM GROUP PIN
MIDF4619OtherMEDICARE RR GROUP
MI1107011701OtherBCBSM IND. PIN
MI080G011310OtherBCBSM GROUP PIN
MI0P31360Medicare PIN