Provider Demographics
NPI:1154499689
Name:BLUMENKEHL, MARK L (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:BLUMENKEHL
Suffix:
Gender:M
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BOULEVARD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-2600
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BOULEVARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054815207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB054815OtherCHAMPUS-CHAMPUS
MI257707610Medicaid
MB054815OtherCOMMERCIAL-COMMERCIAL NUMBER
100H264400OtherBLUE CROSS-BLUE CROSS
MB054815OtherCHAMPUS-CHAMPUS
MI257707610Medicaid