1740210590 NPI number — MARK L CAMENS MD

Table of content: MARK L CAMENS MD (NPI 1740210590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740210590 NPI number — MARK L CAMENS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMENS
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740210590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22100 BOTHELL EVERETT HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOTHELL
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98021-8431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-416-2932
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3210 LEGACY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48323-3634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-687-7237
Provider Business Practice Location Address Fax Number:
855-673-9190
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  0101266424 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 4301069865 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3102510972 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4606613 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4606622 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4606589 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4606598 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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