Provider Demographics
NPI:1043581739
Name:MARK LANGGUT PC
Entity Type:Organization
Organization Name:MARK LANGGUT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:LANGGUT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:708-955-3272
Mailing Address - Street 1:180 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7401
Mailing Address - Country:US
Mailing Address - Phone:708-955-3272
Mailing Address - Fax:708-386-6251
Practice Address - Street 1:180 N MICHIGAN AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7401
Practice Address - Country:US
Practice Address - Phone:708-955-3272
Practice Address - Fax:708-386-6251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003953103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL572430Medicare PIN