Provider Demographics
NPI:1386713196
Name:MART, GARY MARSHALL (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARSHALL
Last Name:MART
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 1:333 N MICHIGAN AVE STE 1525
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-3971
Mailing Address - Country:US
Mailing Address - Phone:312-509-3910
Mailing Address - Fax:312-277-6565
Practice Address - Street 1:333 N MICHIGAN AVE STE 1525
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-3971
Practice Address - Country:US
Practice Address - Phone:312-509-3910
Practice Address - Fax:312-578-1703
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL 036-101902084P0800X, 2084P0804X
IL0361015902084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632730OtherBLUE CROSS BLUE SHIELD
IL624130Medicare UPIN