Healthcare Provider Details

I. General information

NPI: 1871719344
Provider Name (Legal Business Name): BETH MARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 S 36TH ST
PHILADELPHIA PA
19104-3210
US

IV. Provider business mailing address

408 ANTHWYN RD
NARBERTH PA
19072-2302
US

V. Phone/Fax

Practice location:
  • Phone: 215-898-7021
  • Fax:
Mailing address:
  • Phone: 610-213-8945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD042562L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: