MEDICARE: MARYLYN ANN MUDRICK MD029229E

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	MD029229E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5023294	OTHER	AETNA
3	0554265001	OTHER	KEYSTONE BA ST

General Provider Information

NPI Number	:	1639132145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYLYN ANN MUDRICK MD029229E

Provider Business Mailing Address
First Line	:	3303A EDGMOUT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2801
Country	:	US
Telephone Number	:	610-872-0565
Fax Number	:	610-872-4478

Provider Business Practice Location Address
First Line	:	3303A EDGMOUT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2801
Country	:	US
Telephone Number	:	610-872-0565
Fax Number	:	610-872-4478

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	12/31/2024

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