Healthcare Provider Details

I. General information

NPI: 1235103706
Provider Name (Legal Business Name): ROBERT MARK MAYERSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BUNKER HILL DR
ALGONQUIN IL
60102-9780
US

IV. Provider business mailing address

280 W TREEHOUSE LN
ROUND LAKE IL
60073-3597
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-2500
  • Fax:
Mailing address:
  • Phone: 847-546-4368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number96001932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: