=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114994258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CAPKIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2006
-----------------------------------------------------
Last Update Date | 08/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 OLD YORK RD CPC CENTER
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-456-6500
-----------------------------------------------------
Fax | 215-455-1933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E OLNEY AVE 400
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-456-7000
-----------------------------------------------------
Fax | 215-456-5820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD026406E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------