Healthcare Provider Details

I. General information

NPI: 1255725636
Provider Name (Legal Business Name): MARK BALCENIUK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 ROOSEVELT BLVD STE 312
PHILADELPHIA PA
19114-1028
US

IV. Provider business mailing address

1101 MARKET ST FL 19
PHILADELPHIA PA
19107-2926
US

V. Phone/Fax

Practice location:
  • Phone: 215-331-7001
  • Fax: 215-331-7004
Mailing address:
  • Phone: 215-481-6836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD481020
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: