Provider Demographics
NPI:1548286313
Name:SACK, MARK (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2805
Mailing Address - Country:US
Mailing Address - Phone:773-238-7270
Mailing Address - Fax:773-238-9627
Practice Address - Street 1:3216 W 115TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2805
Practice Address - Country:US
Practice Address - Phone:773-238-7270
Practice Address - Fax:773-238-9627
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005080213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005080Medicaid
ILP00267009OtherRAILROAD MEDICARE
IL5488530001Medicare NSC
ILU94620Medicare UPIN
IL5488530001Medicare NSC
ILK15281Medicare PIN
ILK51189Medicare PIN
ILK51190Medicare PIN
IL016005080Medicaid
ILK06429Medicare PIN