Healthcare Provider Details

I. General information

NPI: 1629657317
Provider Name (Legal Business Name): MARTIN GERARD WALSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

1775 DEMPSTER STREET 8 SOUTH, MAILBOX # 48
PARK RIDGE IL
60068
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-2210
  • Fax:
Mailing address:
  • Phone: 847-723-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125078945
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: