Provider Demographics
NPI:1912359126
Name:MANN, GARRY
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:MANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 245A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:SUITE 245A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-364-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine