Healthcare Provider Details

I. General information

NPI: 1942795802
Provider Name (Legal Business Name): KYLE R MARDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2018
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST STE 1900
CHICAGO IL
60611-3246
US

IV. Provider business mailing address

259 E ERIE ST FL 19
CHICAGO IL
60611-2987
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7950
  • Fax: 312-695-5747
Mailing address:
  • Phone: 312-695-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License NumberME160945
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberMT230624
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036174026
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME160945
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: