Provider Demographics
NPI:1336382027
Name:MARK, JAMES RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RYAN
Last Name:MARK
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 1:3500 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4106
Mailing Address - Country:US
Mailing Address - Phone:215-707-3411
Mailing Address - Fax:
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-214-1734
Is Sole Proprietor?:No
Enumeration Date:2009-04-11
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09973500208800000X
NC2015-00289208800000X
PAMD444134208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102843872Medicaid
SCNC2463Medicaid
NJ06649466Medicaid
NC1336382027Medicaid
SCNC2463Medicaid