Provider Demographics
NPI:1063405819
Name:EDELMAN, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:EDELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2901
Mailing Address - Country:US
Mailing Address - Phone:914-682-6430
Mailing Address - Fax:
Practice Address - Street 1:1290 SUMMER ST STE 2100
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5340
Practice Address - Country:US
Practice Address - Phone:855-830-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360946212085R0202X, 2085R0204X
NY172012-12085R0204X
CT518582085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008047540Medicaid
NY01301766Medicaid
IL036094621Medicaid
IL202926OtherGROUP PTAN
IL212545OtherGROUP PTAN
IL789511004Medicare PIN
IL202926009Medicare PIN
MO152670006Medicare PIN
IL202926OtherGROUP PTAN
MODF3698Medicare UPIN
ILP00899969Medicare PIN
MO000015267Medicare UPIN
IL212545012Medicare PIN
IL212545OtherGROUP PTAN
IL036094621Medicaid