=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760428890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK BERMAN D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 02/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10024 SKOKIE BLVD SUITE 303
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-9944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-674-1660
-----------------------------------------------------
Fax | 847-674-2688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2402 E HARBOR RIDGE WAY SUITE E
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-245-4100
-----------------------------------------------------
Fax | 847-245-4420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 16003176
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------