Provider Demographics
NPI:1396923603
Name:MARK S DEVORE, MD PC
Entity type:Organization
Organization Name:MARK S DEVORE, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-751-6034
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:703
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:586-751-6034
Mailing Address - Fax:586-751-6043
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:703
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:586-751-6034
Practice Address - Fax:586-751-6043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMD048964207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE49573Medicare UPIN