Provider Demographics
NPI:1447309786
Name:HERMANOFF, MARK H (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:HERMANOFF
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40807207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32516900Medicaid
WIF73274Medicare UPIN