Basic Information
| Provider Information | |||||||||
| NPI: | 1447660931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1012 | ||||||||
| Address2: | |||||||||
| City: | NEWAYGO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493371012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316522500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 602 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494234918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163925141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2014 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301105002 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | 4301105002 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.