Healthcare Provider Details

I. General information

NPI: 1245586593
Provider Name (Legal Business Name): MATHEW SHAJI MARKOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 S CALIFORNIA AVE SUITE 1001
CHICAGO IL
60608-5146
US

IV. Provider business mailing address

2650 S CALIFORNIA AVE SUITE 1001
CHICAGO IL
60608-5146
US

V. Phone/Fax

Practice location:
  • Phone: 773-674-6123
  • Fax: 773-674-5113
Mailing address:
  • Phone: 773-674-6123
  • Fax: 773-674-5113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number036.071300
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.071300
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: