Provider Demographics
NPI:1457311631
Name:ANKENBRAND, MARK ALAN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:ANKENBRAND
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 297
Mailing Address - Street 2:818 E. BROADWAY
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-0297
Mailing Address - Country:US
Mailing Address - Phone:618-443-2177
Mailing Address - Fax:618-443-1383
Practice Address - Street 1:1300 N. MARKET
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1048
Practice Address - Country:US
Practice Address - Phone:618-443-2177
Practice Address - Fax:618-443-4731
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005036024225100000X
IL070.005247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO221121643Medicare ID - Type Unspecified
MO221124038Medicare ID - Type Unspecified