Basic Information
Provider Information
NPI: 1003803313
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LAY
FirstName: MARK
MiddleName: W
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 117 S BROADWAY ST
Address2:  
City: CASSOPOLIS
State: MI
PostalCode: 490311242
CountryCode: US
TelephoneNumber: 2694450771
FaxNumber:  
Practice Location
Address1: 117 S BROADWAY ST
Address2:  
City: CASSOPOLIS
State: MI
PostalCode: 490311242
CountryCode: US
TelephoneNumber: 2694450771
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/03/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X4301073557MIY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X31145WIN Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X236771NYN Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
LM07355701MIBCBS IND BILLING #OTHER
080381031101MIBCBS IND PIN #OTHER


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