Provider Demographics
NPI:1972870491
Name:JEFFERY A MARK PC
Entity Type:Organization
Organization Name:JEFFERY A MARK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-295-4141
Mailing Address - Street 1:515 S 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516
Mailing Address - Country:US
Mailing Address - Phone:574-295-4141
Mailing Address - Fax:
Practice Address - Street 1:515 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3224
Practice Address - Country:US
Practice Address - Phone:574-295-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039223A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114070BMedicaid
182970Medicare UPIN