Basic Information
| Provider Information | |||||||||
| NPI: | 1598805830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACUMBER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 BUTTERFIELD RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252700 | ||||||||
| FaxNumber: | 6307252783 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 E ONTARIO ST | ||||||||
| Address2: | SUITE 925 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125730614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 036096467 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 202K00000X | 036-096467 | IL | Y | Allopathic & Osteopathic Physicians | Phlebology |
ID Information
| ID | Type | State | Issuer | Description | 789510 | 01 | IL | GROUP MEDICARE PTAN | OTHER | 036096467 | 05 | IL | MEDICAID | 789511 | 01 | IL | GROUP MEDICARE PTAN | OTHER |