Provider Demographics
NPI:1336147354
Name:DANNENBAUM, MARK S (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:DANNENBAUM
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:PO BOX 1710
Mailing Address - Street 2:SOUTH JERSEY RADIOLOGY ASSOCIATES, PA
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-7710
Mailing Address - Country:US
Mailing Address - Phone:856-770-0504
Mailing Address - Fax:856-770-0395
Practice Address - Street 1:100 CARNIE BLVD
Practice Address - Street 2:SUITE B-5
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4512
Practice Address - Country:US
Practice Address - Phone:856-751-0123
Practice Address - Fax:856-751-0535
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA057745002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1243790OtherUNITED HEALTHCARE
NJ5100305Medicaid
1092027OtherHORIZON NJ HEALTH
0732356OtherAETNA
A3738029OtherOXFORD HEALTH
300047103OtherRAILROAD MEDICARE
DA717161OtherPREMIER BLUE
DA717161OtherHIGHMARK PA BLUE SHIELD
0553825000OtherAMERIHEALTH HMO
10654381OtherCAQH
717161OtherAMERIHEALTH PPO
1243790OtherUNITED HEALTHCARE
717161OtherAMERIHEALTH PPO