Provider Demographics
NPI:1750503454
Name:SEVERANCE, MARK WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:SEVERANCE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 DIAMOND POINTE DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-5602
Mailing Address - Country:US
Mailing Address - Phone:224-578-5175
Mailing Address - Fax:
Practice Address - Street 1:300 CENTER DR
Practice Address - Street 2:SUITE 109
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1525
Practice Address - Country:US
Practice Address - Phone:847-984-6460
Practice Address - Fax:847-984-6462
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009481111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207778Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER