Provider Demographics
NPI:1780840488
Name:NESSIM, MARK A (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:NESSIM
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 1:1 KISH HOSPITAL DR.
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9602
Mailing Address - Country:US
Mailing Address - Phone:815-756-1521
Mailing Address - Fax:815-748-8395
Practice Address - Street 1:1 KISH HOSPITAL DR.
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9602
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:815-748-8395
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36.121278207L00000X
IL336.082541207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121278Medicaid
IL201023008Medicare PIN