Provider Demographics
NPI:1861592784
Name:EVENINGRED, MARK HENRY (MPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:EVENINGRED
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48675 AMERICAN ELM DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1429
Mailing Address - Country:US
Mailing Address - Phone:586-263-4910
Mailing Address - Fax:
Practice Address - Street 1:17900 23 MILE RD
Practice Address - Street 2:STE 401
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1161
Practice Address - Country:US
Practice Address - Phone:586-868-9040
Practice Address - Fax:586-868-9013
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist