1083698229 NPI number — MARK FRANCIS OBENRADER MD PHD

Table of content: MARK FRANCIS OBENRADER MD PHD (NPI 1083698229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083698229 NPI number — MARK FRANCIS OBENRADER MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OBENRADER
Provider First Name:
MARK
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1083698229
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 820933
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-0933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-540-8408
Provider Business Mailing Address Fax Number:
215-540-8418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
2ND FL SUITE A
Provider Business Practice Location Address City Name:
FORT WASHINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19034-3314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-540-8408
Provider Business Practice Location Address Fax Number:
215-540-8418
Provider Enumeration Date:
12/01/2005

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: 207Q00000X , with the licence number:  MD025847E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 007057785 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110115445 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00360693 . This is a "RAILROAD MEDICARE TPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 12212 . This is a "BRAVO HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 445439 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3725226 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3Y7167 . This is a "HEALTH NET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4104719 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30019076 . This is a "KEYSTONE MERCY HEALTH PL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0047316000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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