Healthcare Provider Details

I. General information

NPI: 1528089885
Provider Name (Legal Business Name): MARK MROCZKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

105 S MAJOR ST
EUREKA IL
61530-1246
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6900
  • Fax: 208-625-3910
Mailing address:
  • Phone: 309-467-4691
  • Fax: 309-467-6229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM12779
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: