Provider Demographics
NPI:1295838647
Name:RUDBERG, MARK A (MD MPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RUDBERG
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1673
Mailing Address - Country:US
Mailing Address - Phone:847-234-6363
Mailing Address - Fax:847-234-3233
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:STE 101
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1687
Practice Address - Country:US
Practice Address - Phone:847-234-6363
Practice Address - Fax:847-234-3233
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036078815207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E30871Medicare UPIN
IL543350Medicare ID - Type Unspecified