Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 4301082652 | MI |
NPI | 1023080512 |
---|---|
Provider Name | Mansour Miky |
First Address | Marquette, MI 49855-2252 |
Second Address | Marquette, MI 49855-2675 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2006 |
Last Update Date | 20/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2505210422 | BLUE CROSS BLUE SHIELD MI (01) | MI |
4603246 | (05) | MI |
H96933 | (02) | MI |