Provider Demographics
NPI:1730481375
Name:MARK D GENDLEMAN MD SC
Entity Type:Organization
Organization Name:MARK D GENDLEMAN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GENDLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-475-4556
Mailing Address - Street 1:2500 RIDGE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2468
Mailing Address - Country:US
Mailing Address - Phone:847-475-4556
Mailing Address - Fax:847-475-4565
Practice Address - Street 1:2500 RIDGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2468
Practice Address - Country:US
Practice Address - Phone:847-475-4556
Practice Address - Fax:847-475-4565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045834302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization