Provider Demographics
NPI:1164545497
Name:LUCAS, MARK T (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:LUCAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2771 OAK VALLEY DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9244
Practice Address - Country:US
Practice Address - Phone:734-821-7500
Practice Address - Fax:734-821-7501
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN05007271A225100000X
MI5501303559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145210OtherMEDICARE GROUP NUMBER
IL1619980OtherBCBS OF IL