Provider Demographics
NPI:1194740514
Name:LUDVIGSEN, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LUDVIGSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMITT DRIVE
Mailing Address - Street 2:LOCKBOX 1374
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1374
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:6831 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1023
Practice Address - Country:US
Practice Address - Phone:708-298-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0033192363LF0000X
IL209.003905363LF0000X
MI4704397286363LF0000X
NYF351485363LF0000X
IN71013806A363LF0000X
WI1467233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
IL207236003Medicare PIN
ILK14174Medicare PIN
P58978Medicare UPIN