Provider Demographics
NPI:1538140355
Name:PRIMACK, MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:PRIMACK
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 1:100 VILLAGE GRN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-3094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE GRN
Practice Address - Street 2:SUITE 120
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3094
Practice Address - Country:US
Practice Address - Phone:847-634-1766
Practice Address - Fax:847-634-2894
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03605496Medicaid
ILC48767Medicare UPIN
IL03605496Medicaid