Healthcare Provider Details

I. General information

NPI: 1265412753
Provider Name (Legal Business Name): MARINA DEWI LIEM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 RED LION RD
PHILADELPHIA PA
19114-1436
US

IV. Provider business mailing address

101 GREENWOOD AVE STE 150 TRISTATE IMAGING
JENKINTOWN PA
19046
US

V. Phone/Fax

Practice location:
  • Phone: 215-612-4021
  • Fax:
Mailing address:
  • Phone: 215-244-3070
  • Fax: 215-638-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD042422E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: