Provider Demographics
NPI:1427048099
Name:WALSH, MARK M (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3371 CLEVELAND RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9780
Mailing Address - Country:US
Mailing Address - Phone:574-271-2558
Mailing Address - Fax:574-273-1137
Practice Address - Street 1:801 E LASALLE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2814
Practice Address - Country:US
Practice Address - Phone:574-237-7111
Practice Address - Fax:574-273-1137
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-10-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01035916A207R00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100318660Medicaid
IN146470NNNNMedicare ID - Type Unspecified
IN100318660Medicaid
IN176490MMedicare PIN