Provider Demographics
NPI:1497701858
Name:MULLEN, GEORGE MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:MARTIN
Last Name:MULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARTIN
Other - Middle Name:
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:900 S FRONTAGE RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4903
Mailing Address - Country:US
Mailing Address - Phone:847-981-3680
Mailing Address - Fax:847-956-5122
Practice Address - Street 1:800 BIESTERFIELD RD # SUITEG01
Practice Address - Street 2:WIMMER BUILDING
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-981-3680
Practice Address - Fax:847-956-5122
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057900207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6304010OtherMEDICARE PTAN LOC 16
ILIL6305010OtherMEDICARE PTAN LOC 15
ILP01013365OtherRRMC PTAN
IL1720371669OtherNPI GROUP PRACTICE
ILIL6305010OtherMEDICARE PTAN LOC 15