Provider Demographics
NPI:1194288944
Name:PRESSPRICH, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PRESSPRICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-7960
Practice Address - Street 1:19117 ALLEN RD STE A
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1066
Practice Address - Country:US
Practice Address - Phone:734-676-4040
Practice Address - Fax:734-676-9897
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301511048208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194288944Medicaid
MI4301511048OtherMI MEDICAL LICENSE