Provider Demographics
NPI:1346277274
Name:AMDUR, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AMDUR
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 1:4250 N MARINE DR
Mailing Address - Street 2:SUITE 236
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1744
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:
Practice Address - Street 1:6201 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1108
Practice Address - Country:US
Practice Address - Phone:708-386-0845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360443052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044305Medicaid
IL774810Medicare ID - Type Unspecified
IL036044305Medicaid