Healthcare Provider Details

I. General information

NPI: 1588999585
Provider Name (Legal Business Name): MINA E. MARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E CHELTEN AVE
PHILADELPHIA PA
19144-2153
US

IV. Provider business mailing address

500 S BROAD ST SUITE 360
PHILADELPHIA PA
19146-1613
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-5701
  • Fax: 215-685-5748
Mailing address:
  • Phone: 215-685-6769
  • Fax: 215-685-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD041619L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: