Provider Demographics
NPI:1386693497
Name:KRUCK, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:KRUCK
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:ST. MARYS HOSPITAL/DEAN MEDICAL CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1849
Mailing Address - Country:US
Mailing Address - Phone:608-258-6975
Mailing Address - Fax:608-258-5222
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:ST. MARYS HOSPITAL/DEAN MEDICAL CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1849
Practice Address - Country:US
Practice Address - Phone:608-258-6975
Practice Address - Fax:608-258-5222
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI44258-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1386693497Medicaid
WI34256300Medicaid
H63073Medicare UPIN
WI34256300Medicaid
WI076574150Medicare PIN