Healthcare Provider Details

I. General information

NPI: 1508833609
Provider Name (Legal Business Name): MARYLEE MUNDELL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 OLD YORK RD SUITE 620
JENKINTOWN PA
19046-3706
US

IV. Provider business mailing address

261 OLD YORK RD SUITE 620
JENKINTOWN PA
19046-3706
US

V. Phone/Fax

Practice location:
  • Phone: 215-885-8700
  • Fax: 215-885-8795
Mailing address:
  • Phone: 215-885-8700
  • Fax: 215-885-8795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS008765-L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0016762580005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: