Provider Demographics
NPI:1598708877
Name:LEISCHNER, MARK PAUL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:LEISCHNER
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 1:210 S DESPLAINES ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5500
Mailing Address - Country:US
Mailing Address - Phone:312-654-2700
Mailing Address - Fax:312-654-9930
Practice Address - Street 1:2608 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5905
Practice Address - Country:US
Practice Address - Phone:773-756-3333
Practice Address - Fax:773-525-3416
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110702207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110702Medicaid
I53201Medicare UPIN
IL036110702Medicaid