Healthcare Provider Details

I. General information

NPI: 1629156559
Provider Name (Legal Business Name): MARK D MINIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S CALIFORNIA AVE STE 100
CHICAGO IL
60608
US

IV. Provider business mailing address

2001 S CALIFORNIA AVE STE 100
CHICAGO IL
60608-2486
US

V. Phone/Fax

Practice location:
  • Phone: 773-584-6200
  • Fax:
Mailing address:
  • Phone: 773-640-5785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036137053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: