Provider Demographics
NPI:1114181658
Name:KELDAHL, MARK LOREN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LOREN
Last Name:KELDAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:3000 N. HALSTED ST.
Practice Address - Street 2:SUITE 703
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-296-3390
Practice Address - Fax:773-296-7531
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN595172086S0129X
IL036117220208600000X
IL036-117220208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery