Provider Demographics
NPI:1275543910
Name:MULLENDORE, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MULLENDORE
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:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-670-2424
Mailing Address - Fax:217-670-2809
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-9722
Practice Address - Fax:217-391-0392
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054501OtherHEALTH ALLIANCE
IL08421024OtherBC/BS
IL110140987OtherRR MEDICARE PIN
IL133586700OtherACS-OWCP
IL101525OtherHEALTHLINK
ILCD7143OtherRR MEDICARE GROUP
IL6394POtherCATERPILLAR
IL020057300OtherBLACK LUNG
IL036057331OtherIL STATE LICENSE
IL036057331Medicaid
IL14D0949277OtherCLIA
IL170777OtherPERSONAL CARE
ILCD7143OtherRR MEDICARE GROUP