MEDICARE: MR. MARK ALLEN DONATHAN MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT012924L	PA
2	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11351751	OTHER	PA	CAQH
2	1333102	OTHER	PA	HIGHMARK
3	2025970000	OTHER	PA	AMERIHEALTH
4	2025970000	OTHER	PA	IBC

General Provider Information

NPI Number	:	1760481154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ALLEN DONATHAN MPT

Provider Business Mailing Address
First Line	:	10980 NORCOM RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19154-2302
Country	:	US
Telephone Number	:	215-872-3595
Fax Number	:

Provider Business Practice Location Address
First Line	:	10980 NORCOM RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19154-2302
Country	:	US
Telephone Number	:	215-872-3595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	12/17/2021

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