Provider Demographics
NPI:1851404313
Name:PASSERMAN, MARK A (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:PASSERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:101 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420
Practice Address - Country:US
Practice Address - Phone:815-584-3291
Practice Address - Fax:815-584-3475
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116449-1Medicaid
IL036116449-1Medicaid
ILI63513Medicare UPIN