Healthcare Provider Details

I. General information

NPI: 1841276847
Provider Name (Legal Business Name): MARK E MASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W EVERETT RD SUITE 101
LAKE FOREST IL
60045-2697
US

IV. Provider business mailing address

475 MCCORMICK DR
LAKE FOREST IL
60045-3349
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-7950
  • Fax: 847-234-7940
Mailing address:
  • Phone: 847-814-9376
  • Fax: 847-234-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number36093222
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number036-093222
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036-093222
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-093222
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number036-093222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: