Individual
MARK C ANTONISHEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
223 N PARK ST, BOYNE CITY, MI 49712-1220
(231) 582-8010
(231) 582-5338
Mailing address
10850 E TRAVERSE HWY, SUITE 4400, TRAVERSE CITY, MI 49684-1364
(231) 346-6800
(989) 340-1214
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
4301046169
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104102303
—
MI
01
—
1102408031
BCBSM PIN
MI
01
—
23D0963677
CLIA
MI
01
—
MA046169
BS STATE LIC#
MI
Enumeration date
07/27/2006
Last updated
02/02/2024
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