MEDICARE: MARK D GENDLEMAN 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	174400000X	Specialist	036045834	IL

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	:	1457339863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK D GENDLEMAN M.D.

Provider Business Mailing Address
First Line	:	2500 RIDGE AVE
Second Line	:	SUITE 103
City	:	EVANSTON
State	:	IL
Zip	:	60201-2455
Country	:	US
Telephone Number	:	847-475-4556
Fax Number	:	847-475-4565

Provider Business Practice Location Address
First Line	:	2500 RIDGE AVE
Second Line	:	SUITE 103
City	:	EVANSTON
State	:	IL
Zip	:	60201-2455
Country	:	US
Telephone Number	:	847-475-4556
Fax Number	:	847-475-4565

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

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	03/11/2015

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