1083698229 NPI number — MARK FRANCIS OBENRADER MD PHD

Table of content: BAHAR IRANMEHR D.D.S (NPI 1619589629)

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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