Provider Demographics
NPI:1740243369
Name:STID, MARK ANDREW (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:STID
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3719
Mailing Address - Country:US
Mailing Address - Phone:616-396-2972
Mailing Address - Fax:855-863-9540
Practice Address - Street 1:270 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3719
Practice Address - Country:US
Practice Address - Phone:616-396-2972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055336207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3164034 10Medicaid
MIOM13670Medicare ID - Type Unspecified
MIG13993Medicare UPIN