Provider Demographics
NPI:1366433567
Name:IRWIN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:IRWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:618-234-0640
Mailing Address - Fax:314-851-4475
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 904
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-234-0640
Practice Address - Fax:314-851-4475
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336-023425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058840Medicaid
IL000000010019OtherESSENCE
IL113626OtherHEALTHLINK
IL8221955OtherBCBS IL
IL127443OtherGHP
IL129537OtherBCBS TRI ST
IL129537OtherBCBS
IL0450347OtherUHC
IL5561291OtherAETNA
ILD14440OtherMERCY
IL127443OtherGHP
ILL69258Medicare PIN
IL110182190Medicare PIN