Provider Demographics
NPI:1942300454
Name:GRENQUIST, MARK FRANCIS (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:FRANCIS
Last Name:GRENQUIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 - LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:775 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1383
Practice Address - Country:US
Practice Address - Phone:734-593-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014936207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942300454Medicaid
MI1417961137OtherBCBSM - BRONSON BATTLE CREEK
MI5331090OtherBCBS INDIVIDUAL PIN
MI4631106Medicaid
MI1417961137OtherBCBSM - BRONSON BATTLE CREEK
MIC97618303 - BRONSONMedicare PIN
MI4631106Medicaid
MIM77890010Medicare PIN