Provider Demographics
NPI:1598805830
Name:MACUMBER, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MACUMBER
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 1:3114 W IRVING PARK RD STE 1W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3435
Mailing Address - Country:US
Mailing Address - Phone:312-600-4526
Mailing Address - Fax:714-363-3847
Practice Address - Street 1:3875 E OVERLAND RD STE 202
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9048
Practice Address - Country:US
Practice Address - Phone:208-600-1550
Practice Address - Fax:208-600-1551
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096467207Q00000X
IL036-096467202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL789510OtherGROUP MEDICARE PTAN
IL789511OtherGROUP MEDICARE PTAN
IL036096467Medicaid
IL036096467Medicaid
ILF400234442Medicare PIN
ILF400234443Medicare PIN