Provider Demographics
NPI:1225079379
Name:DAVIS, MARK (MD,FACS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-343-7773
Mailing Address - Fax:309-343-3839
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:SUITE 503
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-343-7773
Practice Address - Fax:309-343-3839
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL344-670Medicare ID - Type Unspecified
ILG26930Medicare UPIN