1003435926 NPI number — DR. KYLE CORSO MORK PHARMD, MBA

Table of content: DR. KYLE CORSO MORK PHARMD, MBA (NPI 1003435926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003435926 NPI number — DR. KYLE CORSO MORK PHARMD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORK
Provider First Name:
KYLE
Provider Middle Name:
CORSO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, MBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003435926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
163 NORTHGATE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60546-1683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-464-5349
Provider Business Mailing Address Fax Number:
312-996-8525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 S WOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-4325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-6783
Provider Business Practice Location Address Fax Number:
312-996-8525
Provider Enumeration Date:
04/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P2201X , with the licence number:  049168241 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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