Healthcare Provider Details

I. General information

NPI: 1386805570
Provider Name (Legal Business Name): MARK TOMERA MC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7579 LAKE ST
RIVER FOREST IL
60305-1846
US

IV. Provider business mailing address

7579 LAKE ST
RIVER FOREST IL
60305-1846
US

V. Phone/Fax

Practice location:
  • Phone: 708-366-7177
  • Fax:
Mailing address:
  • Phone: 708-366-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036065652
License Number StateIL

VIII. Authorized Official

Name: ELIZABETH BRUNDGAE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 708-366-7177