Provider Demographics
NPI:1679557763
Name:JANICH, MARK RICHARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:JANICH
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 1:1 INDEPENDENCE PLZ
Mailing Address - Street 2:STE 900
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-2629
Mailing Address - Country:US
Mailing Address - Phone:205-271-8000
Mailing Address - Fax:205-879-0548
Practice Address - Street 1:1 INDEPENDENCE PLZ
Practice Address - Street 2:STE 900
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-2629
Practice Address - Country:US
Practice Address - Phone:205-271-8000
Practice Address - Fax:205-879-0548
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14049207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528400180Medicaid
AL82978Medicare ID - Type Unspecified
C72962Medicare UPIN