Provider Demographics
NPI:1598783227
Name:HALSTEAD, MARK EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:HALSTEAD
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-514-3500
Mailing Address - Fax:314-878-7678
Practice Address - Street 1:14532 S OUTER 40 RD
Practice Address - Street 2:DEPT ORTHOPAEDIC SURGERY, STE 200
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5705
Practice Address - Country:US
Practice Address - Phone:314-514-3500
Practice Address - Fax:314-878-7678
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040117742080S0010X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209144609Medicaid
ILENROLLEDMedicaid
MO918680232Medicare PIN
MOP00234177Medicare PIN