Basic Information
| Provider Information | |||||||||
| NPI: | 1548350432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNIBAL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DR | ||||||||
| Address2: | 6TH FLOOR MOTT CHILDRENS HOSPITAL | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481094259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349364185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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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 | 207SG0201X | MD00037850 | WA | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207SG0201X | 4301099786 | MI | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208000000X | 4301099786 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3199 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 8246647 | 05 | WA | MEDICAID |