Provider Demographics
NPI:1396749719
Name:MARR, MITCHELL HARRY (DC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:HARRY
Last Name:MARR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 S ORTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8819
Mailing Address - Country:US
Mailing Address - Phone:248-627-8264
Mailing Address - Fax:248-627-7370
Practice Address - Street 1:1770 S ORTONVILLE RD
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8819
Practice Address - Country:US
Practice Address - Phone:248-627-8264
Practice Address - Fax:248-627-7370
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM 005040111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2645336Medicaid
MI0M65640Medicare ID - Type Unspecified
MIT33732Medicare UPIN