Provider Demographics
NPI:1518977974
Name:MARK BERMAN D.P.M.
Entity Type:Organization
Organization Name:MARK BERMAN D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-674-1660
Mailing Address - Street 1:2402 E HARBOR RIDGE WAY
Mailing Address - Street 2:SUITE E
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-4911
Mailing Address - Country:US
Mailing Address - Phone:847-245-4100
Mailing Address - Fax:847-245-4420
Practice Address - Street 1:10024 SKOKIE BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-9944
Practice Address - Country:US
Practice Address - Phone:847-674-1660
Practice Address - Fax:847-674-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16003176213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003176Medicaid
IL016003176Medicaid
ILT37488Medicare UPIN