Provider Demographics
NPI:1225130933
Name:WASSERMAN, MARK STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STANLEY
Last Name:WASSERMAN
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 1:2100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4701
Mailing Address - Country:US
Mailing Address - Phone:618-451-4872
Mailing Address - Fax:618-451-6203
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-451-4872
Practice Address - Fax:618-451-6203
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104995207V00000X
MOR2F91207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104995Medicaid
IL036104995Medicaid
ILA10646Medicare UPIN