Healthcare Provider Details

I. General information

NPI: 1255992855
Provider Name (Legal Business Name): DR. ANDREW HALLMARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

U OF M DEPARTMENT OF ANESTHESIOLOGY 1500 E MEDICAL CTR 1H241 UH
ANN ARBOR MI
48109-5048
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4800
  • Fax:
Mailing address:
  • Phone: 734-936-4280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351044182
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.164135
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: