Basic Information
| Provider Information | |||||||||
| NPI: | 1013932409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEFANIUK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 W RAND RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | MT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600561157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185450 | ||||||||
| FaxNumber: | 8476185459 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 W. RAND ROAD | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600561129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185450 | ||||||||
| FaxNumber: | 5476185459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-109698 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 89349 (ID#) | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 036-109698 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036109698-4 | 05 | IL | MEDICAID | 036109698 | 05 | IL | MEDICAID |