Provider Demographics
NPI:1164545497
Name:LUCAS, MARK T (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:LUCAS
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:5525 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-884-2827
Mailing Address - Fax:219-884-2891
Practice Address - Street 1:5525 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-884-2827
Practice Address - Fax:219-884-2891
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007271A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145210OtherMEDICARE GROUP NUMBER
IL1619980OtherBCBS OF IL