Basic Information
| Provider Information | |||||||||
| NPI: | 1518991074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PLUNKETT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 NE GLEN OAK AVE STE 301 | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
| FaxNumber: | 3096243852 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 NE GLEN OAK AVE STE 301 | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
| FaxNumber: | 3096243852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/28/2016 | ||||||||
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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 | 208G00000X | 42233 | KY | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 036-093440 | IL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 7100053080 | 05 | KY | MEDICAID | 00G809460 | 05 | CA | MEDICAID |