Provider Demographics
NPI:1184880668
Name:DR MARK P WILLIAMS PC
Entity type:Organization
Organization Name:DR MARK P WILLIAMS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-715-2020
Mailing Address - Street 1:4067 E COURT ST # 10-11
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2509
Mailing Address - Country:US
Mailing Address - Phone:810-715-2020
Mailing Address - Fax:
Practice Address - Street 1:4067 E COURT ST # 10-11
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-2509
Practice Address - Country:US
Practice Address - Phone:810-715-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI202115OtherMCLAREN HEALTH PLAN
MI5104868Medicaid
MIOB56586OtherBLUE CROSS/BLUE SHIELD OF MICHIGAN
MI0B56586Medicare PIN
MIT32807Medicare UPIN
MI0199530001Medicare NSC