Provider Demographics
NPI:1053399220
Name:KOEHL, MARK THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:KOEHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8765 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9583
Mailing Address - Country:US
Mailing Address - Phone:734-847-3802
Mailing Address - Fax:734-847-3418
Practice Address - Street 1:8765 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9583
Practice Address - Country:US
Practice Address - Phone:734-847-3802
Practice Address - Fax:734-847-3418
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2652573Medicaid
MI05816OtherHEALTH PLAN OF MICHIGAN
MI700E86031OtherBCBS OF MICHIGAN
OH2047421Medicaid
MI02214OtherPARAMOUNT HEALTH CARE
OH2047421Medicaid
OH9310221Medicare PIN
OH4024381Medicare PIN
MI2652573Medicaid
MI05816OtherHEALTH PLAN OF MICHIGAN