Provider Demographics
NPI:1396772661
Name:MARK, MY N (MD)
Entity type:Individual
Prefix:
First Name:MY
Middle Name:N
Last Name:MARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 N HOWE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7686
Mailing Address - Country:US
Mailing Address - Phone:847-867-8030
Mailing Address - Fax:
Practice Address - Street 1:4600 N RAVENSWOOD AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4510
Practice Address - Country:US
Practice Address - Phone:773-561-7500
Practice Address - Fax:773-561-7612
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036111701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI25826Medicare UPIN