Healthcare Provider Details

I. General information

NPI: 1225087752
Provider Name (Legal Business Name): MARK SHUKHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 GOLF RD SUITE 1200
SKOKIE IL
60076-1224
US

IV. Provider business mailing address

4711 GOLF RD SUITE 1200
SKOKIE IL
60076-1224
US

V. Phone/Fax

Practice location:
  • Phone: 847-563-4488
  • Fax: 847-929-9355
Mailing address:
  • Phone: 847-563-4488
  • Fax: 847-929-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-103040
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number036-103040
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036-103040
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number36-103040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: