Provider Demographics
NPI:1366605362
Name:MAR, ANNIE (MD)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:MAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43555 DALCOMA DR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6310
Mailing Address - Country:US
Mailing Address - Phone:586-228-2882
Mailing Address - Fax:586-463-7152
Practice Address - Street 1:43555 DALCOMA DR
Practice Address - Street 2:SUITE #4
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6310
Practice Address - Country:US
Practice Address - Phone:586-228-2882
Practice Address - Fax:586-463-7152
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254547208100000X
MI4301097750208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03154432Medicaid
NY03154432Medicaid
NYJ400006564Medicare PIN
MIE06114017Medicare PIN