Provider Demographics
NPI:1639172570
Name:HEAD, MARK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:HEAD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:301 GORDON GUTMANN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3765
Practice Address - Country:US
Practice Address - Phone:812-282-4844
Practice Address - Fax:812-282-6248
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01052682A207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64026982Medicaid
IN200262820Medicaid
KY34228OtherSTATE LICENSE
IN01052682AOtherSTATE LICENSE