Individual
DR. MARK JAY MCGILLEM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5215 HOLY CROSS PKWY, MISHAWAKA, IN 46545-1469
(574) 335-2521
(574) 335-2262
Mailing address
810 PARK PL, MISHAWAKA, IN 46545-3520
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01051194A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000735776
BCBS
IN
05
—
200233400
—
IN
Enumeration date
11/02/2005
Last updated
03/15/2012
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