Basic Information
| Provider Information | |||||||||
| NPI: | 1104807452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 6465 MILLENNIUM | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489177831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173675220 | ||||||||
| FaxNumber: | 5173675245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301049237 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204119 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | F05598 | 01 | MI | HEALTH NET FEDERAL SERVIC | OTHER | 7720197 | 01 | MI | AETNA | OTHER | 0400264 | 01 | MI | PHYSICIANS HEALTH PLAN | OTHER | 204119 | 01 | MI | HEALTH ADVANTAGE | OTHER | 1103302772 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 4130522 | 05 | MI | MEDICAID |