Provider Demographics
NPI:1174544514
Name:LITTLEHALE, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:LITTLEHALE
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 1:4199 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8940
Mailing Address - Country:US
Mailing Address - Phone:812-842-4108
Mailing Address - Fax:812-842-4227
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8940
Practice Address - Country:US
Practice Address - Phone:812-842-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35408207V00000X
IN01077457A207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016537Medicaid
KY35408OtherKENTUCKY MEDICAL LICENSE
000000108276OtherBCBS PROVIDER NUMBER
KY64003163Medicaid
KY160048897Medicare PIN
0536347Medicare PIN
000000108276OtherBCBS PROVIDER NUMBER
0600213Medicare PIN
0570247Medicare PIN
0691604Medicare PIN