Basic Information
| Provider Information | |||||||||
| NPI: | 1710340724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGNUS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4340 | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600160014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 E GOLF RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600161253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2016 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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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 | 213E00000X | 1138 | WI | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 1138 | WI | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | 016005815 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.