Provider Demographics
NPI:1548232234
Name:MARK EDELSTEIN, MD, PC
Entity Type:Organization
Organization Name:MARK EDELSTEIN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-1744
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-1744
Mailing Address - Fax:618-288-2544
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 20
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-1744
Practice Address - Fax:618-288-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212504Medicare PIN