MEDICARE: DR. SUSAN L MARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	55708	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225091606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN L MARK M.D.

Provider Business Mailing Address
First Line	:	2925 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1321
Country	:	US
Telephone Number	:	612-262-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 FORD PKWY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1863
Country	:	US
Telephone Number	:	651-241-9600
Fax Number	:	651-241-9593

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	07/16/2013

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