Provider Demographics
NPI:1679536577
Name:MULTACH, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MULTACH
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 1:850 N LAKE SHORE DR
Mailing Address - Street 2:201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6324
Mailing Address - Country:US
Mailing Address - Phone:312-618-9922
Mailing Address - Fax:
Practice Address - Street 1:850 N LAKE SHORE DR
Practice Address - Street 2:201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-6324
Practice Address - Country:US
Practice Address - Phone:315-618-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0407275-00Medicaid
FL0407275-00Medicaid
FLD63964Medicare UPIN