Healthcare Provider Details

I. General information

NPI: 1063405819
Provider Name (Legal Business Name): MARK A EDELMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 SUMMER ST STE 2100
STAMFORD CT
06905-5340
US

IV. Provider business mailing address

210 WESTCHESTER AVE
WHITE PLAINS NY
10604-2901
US

V. Phone/Fax

Practice location:
  • Phone: 855-830-8346
  • Fax:
Mailing address:
  • Phone: 914-682-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036094621
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036094621
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number172012-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number51858
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: