Provider Demographics
NPI:1942248794
Name:BRANDT, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:BRANDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S NORTHWEST HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4262
Mailing Address - Country:US
Mailing Address - Phone:847-470-1500
Mailing Address - Fax:847-470-1550
Practice Address - Street 1:350 S NORTHWEST HWY STE 106
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4262
Practice Address - Country:US
Practice Address - Phone:847-470-1500
Practice Address - Fax:847-470-1550
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084697208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00268096OtherRAILROAD MEDICARE
IL036084697Medicaid
IL036084697Medicaid
ILP00268096OtherRAILROAD MEDICARE