Provider Demographics
NPI:1922086560
Name:BLITSTEIN, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BLITSTEIN
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 1:800 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1673
Mailing Address - Country:US
Mailing Address - Phone:847-295-1300
Mailing Address - Fax:847-295-1574
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-295-1300
Practice Address - Fax:847-295-1574
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL83880Medicare ID - Type Unspecified
ILC40398Medicare UPIN