Provider Demographics
NPI:1740287101
Name:GEISSLER, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GEISSLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 W FAIR AVENUE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3853
Mailing Address - Fax:906-228-4065
Practice Address - Street 1:1414 W FAIR AVENUE
Practice Address - Street 2:SUITE 230
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3853
Practice Address - Fax:906-228-4065
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG0611712086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2952097Medicaid
MI0523259OtherBLUE CROSS/BLUE SHIELD
F60037Medicare UPIN
MIF60037Medicare UPIN
MI2952097Medicaid