Healthcare Provider Details

I. General information

NPI: 1598805830
Provider Name (Legal Business Name): MARK MACUMBER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3277 E LOUISE DR STE 360
MERIDIAN ID
83642-9359
US

IV. Provider business mailing address

3114 W IRVING PARK RD STE 1W
CHICAGO IL
60618-3435
US

V. Phone/Fax

Practice location:
  • Phone: 208-600-1550
  • Fax: 208-600-1551
Mailing address:
  • Phone: 312-600-4526
  • Fax: 714-363-3847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036096467
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number036-096467
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: