Provider Demographics
NPI:1720413784
Name:MARK, KEVIN (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:6500 EASTERN AVE
Practice Address - Street 2:STE E&F
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2900
Practice Address - Country:US
Practice Address - Phone:410-633-3670
Practice Address - Fax:410-633-3674
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036727225100000X
MD24735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist