Basic Information
| Provider Information | |||||||||
| NPI: | 1831142306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MECANO | ||||||||
| FirstName: | LITON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 10047 CROSSROAD CT SE | ||||||||
| Address2: | |||||||||
| City: | CALEDONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493167316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858450 | ||||||||
| FaxNumber: | 6164583526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/29/2009 | ||||||||
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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 | 207Q00000X | 4301062209 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4208447 | 05 | MI | MEDICAID | 4878346 | 05 | MI | MEDICAID | 4155559 | 05 | MI | MEDICAID | 3415760 | 05 | MI | MEDICAID | 4186116 | 05 | MI | MEDICAID | 4879011 | 05 | MI | MEDICAID | 4212691 | 05 | MI | MEDICAID | 4555004 | 05 | MI | MEDICAID | 4749643 | 05 | MI | MEDICAID | 4181728 | 05 | MI | MEDICAID |