Provider Demographics
NPI:1568419463
Name:BOWEN, MARK K (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:BOWEN
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 1:680 N LAKE SHORE DR STE 924
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8701
Mailing Address - Country:US
Mailing Address - Phone:847-866-7846
Mailing Address - Fax:866-954-5787
Practice Address - Street 1:680 N LAKE SHORE DR STE 924
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:866-954-5787
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082429207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-082429Medicaid
ILK32529Medicare PIN
ILE91839Medicare UPIN