Provider Demographics
NPI:1013962216
Name:NEWBERRY, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:NEWBERRY
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 1:5838 METRO WAY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9619
Mailing Address - Country:US
Mailing Address - Phone:616-249-5300
Mailing Address - Fax:
Practice Address - Street 1:5838 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9619
Practice Address - Country:US
Practice Address - Phone:616-249-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4771107Medicaid
MI4770905Medicaid
MI4773836Medicaid
MI4770950Medicaid
MI4774029Medicaid
MI0D161147OtherBCBS
MI1598712390OtherGROUP NPI
MI1598712390OtherGROUP NPI
MI0M33350081Medicare ID - Type Unspecified
MI4770950Medicaid
MI4770905Medicaid