Provider Demographics
NPI:1396844858
Name:EFRUSY, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:EFRUSY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SUPERIOR AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4037
Mailing Address - Country:US
Mailing Address - Phone:219-922-3040
Mailing Address - Fax:219-922-3048
Practice Address - Street 1:701 SUPERIOR AVE
Practice Address - Street 2:SUITE G
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4037
Practice Address - Country:US
Practice Address - Phone:219-922-3040
Practice Address - Fax:219-922-3048
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000882207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050964Medicaid
IN100201780AMedicaid
ILK19096Medicare PIN
IL036050964Medicaid