Healthcare Provider Details

I. General information

NPI: 1780754127
Provider Name (Legal Business Name): MARK AUSTIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LINCOLN DR STE D
HERRIN IL
62948-6355
US

IV. Provider business mailing address

PO BOX 1105
INDIANAPOLIS IN
46206-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-5200
  • Fax: 618-529-0568
Mailing address:
  • Phone: 618-457-5200
  • Fax: 618-529-0568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036079878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: