Provider Demographics
NPI:1902258007
Name:TESANOVICH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TESANOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6673 MASSACHUSETTS ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3518
Mailing Address - Country:US
Mailing Address - Phone:219-808-3171
Mailing Address - Fax:
Practice Address - Street 1:8601 N KENTUCKY AVE STE A
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725-6371
Practice Address - Country:US
Practice Address - Phone:812-469-6877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRT13364227900000X
IN30003311A227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered