Provider Demographics
NPI:1841276847
Name:MASS, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MASS
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 1:475 MCCORMICK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-3349
Mailing Address - Country:US
Mailing Address - Phone:847-814-9376
Mailing Address - Fax:847-234-7940
Practice Address - Street 1:1025 W EVERETT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2697
Practice Address - Country:US
Practice Address - Phone:847-234-7950
Practice Address - Fax:847-234-7940
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36093222207PE0004X
IL036-093222261QU0200X, 2083X0100X, 207P00000X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36093222Medicaid
ILE64401Medicare UPIN
IL36093222Medicaid