Provider Demographics
NPI:1811070949
Name:CIMMERER, MARK W (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:CIMMERER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7339
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43014069402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300023174OtherRAILROAD MEDICARE
MI300023192OtherRAILROAD MEDICARE
MI2829389Medicaid
MI2824810Medicaid
MI200000001748OtherPHP OF MIDMICHIGAN
MI2832974Medicaid
MI2829389Medicaid
MI0C37603014Medicare ID - Type Unspecified
MI2832974Medicaid