Provider Demographics
NPI:1083690093
Name:TRAVIS, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:TRAVIS
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 1:1229 N NORTH BRANCH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2473
Mailing Address - Country:US
Mailing Address - Phone:312-939-5090
Mailing Address - Fax:312-640-4496
Practice Address - Street 1:1229 N NORTH BRANCH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2473
Practice Address - Country:US
Practice Address - Phone:312-939-5090
Practice Address - Fax:312-640-4496
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061315A207R00000X, 207RN0300X
IL207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01061315AOtherLICENSE NUMBER
IN000000383791OtherANTHEM PROVIDER NUMBER
E61569Medicare UPIN
IN000000383791OtherANTHEM PROVIDER NUMBER