Basic Information
| Provider Information | |||||||||
| NPI: | 1265410856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036098447 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 36159 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 220756-1 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 578210022 | 01 | IA | MEDICARE PTAN | OTHER | IA01C2 | 01 | JOHN DEERE FAMILY | OTHER | K18135 | 01 | IL | MEDICARE PTAN | OTHER | 8121085 | 01 | IL | BCBS | OTHER | 94370 | 01 | WELLMARK | OTHER | 0592337 | 05 | IA | MEDICAID | 247584 | 01 | MIDLANDS CHOICE | OTHER | 39336 | 01 | WELLMARK | OTHER | 526253 | 01 | IA HEALTH SOLUTIONS | OTHER | 91946 | 01 | WELLMARK | OTHER | 91947 | 01 | WELLMARK | OTHER | 036098447 | 05 | IL | MEDICAID | 107468 | 01 | HEALTH ALLIANCE | OTHER | IL01B9 | 01 | JOHN DEERE FAMILY | OTHER | P00244895 | 01 | RR MEDICARE | OTHER |