Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | IL |
NPI | 1134285539 |
---|---|
Provider Name | Mark A Spencer |
First Address | Lemont, IL 60439-3680 |
Second Address | Lemont, IL 60439-3680 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02232712 | BLUE CROSS BLUE SHIELD IL (01) | IL |