Provider Demographics
NPI:1457339863
Name:GENDLEMAN, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:GENDLEMAN
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 1:2500 RIDGE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2455
Mailing Address - Country:US
Mailing Address - Phone:847-475-4556
Mailing Address - Fax:847-475-4565
Practice Address - Street 1:2500 RIDGE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2455
Practice Address - Country:US
Practice Address - Phone:847-475-4556
Practice Address - Fax:847-475-4565
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045834Medicaid
D13057Medicare UPIN
IL1457339863Medicare NSC