Healthcare Provider Details

I. General information

NPI: 1407484645
Provider Name (Legal Business Name): MACUMBER MEDICAL LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 833-388-7669
  • Fax: 833-388-7669
Mailing address:
  • Phone: 833-388-7669
  • Fax: 833-388-7669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK MACUMBER
Title or Position: OWNER
Credential: MD
Phone: 773-220-0376