Healthcare Provider Details

I. General information

NPI: 1972870491
Provider Name (Legal Business Name): JEFFERY A MARK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S 2ND ST
ELKHART IN
46516-3224
US

IV. Provider business mailing address

515 S 2ND STREET
ELKHART IN
46516
US

V. Phone/Fax

Practice location:
  • Phone: 574-295-4141
  • Fax:
Mailing address:
  • Phone: 574-295-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01039223A
License Number StateIN

VIII. Authorized Official

Name: JEFF MARK
Title or Position: OWNER
Credential:
Phone: 574-295-4141