1821082892 NPI number — DR. MICHAEL H MARK MD

Table of content: DR. MICHAEL H MARK MD (NPI 1821082892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821082892 NPI number — DR. MICHAEL H MARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARK
Provider First Name:
MICHAEL
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1821082892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28467 DUPONT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLSBORO
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19966-3749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-933-0111
Provider Business Mailing Address Fax Number:
302-933-0990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28467 DUPONT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILLSBORO
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19966-3749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-933-0111
Provider Business Practice Location Address Fax Number:
302-933-0990
Provider Enumeration Date:
09/07/2005

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: 2084N0400X , with the licence number:  C1-0003541 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51038312C . This is a "BLUE SHIELD DE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 265039 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4275007 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: D000288 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: KG82 . This is a "MD BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: C08438 . This is a "MID ATLANTIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0000245501 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130018400 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: G2420004 . This is a "DELMARVA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".




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