Healthcare Provider Details

I. General information

NPI: 1477675635
Provider Name (Legal Business Name): MARK WARNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 STATE ROAD STE 2-900
DREXEL HILL PA
19026-4653
US

IV. Provider business mailing address

5030 STATE ROAD STE 2-900
DREXEL HILL PA
19026-4653
US

V. Phone/Fax

Practice location:
  • Phone: 610-623-9080
  • Fax: 610-623-3861
Mailing address:
  • Phone: 610-623-9080
  • Fax: 610-623-3861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS005359L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0010979340002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: