Provider Demographics
NPI:1568450468
Name:KRAEMER, MARY S (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:KRAEMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-1800
Mailing Address - Fax:215-707-3644
Practice Address - Street 1:3322 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5185
Practice Address - Country:US
Practice Address - Phone:215-707-1800
Practice Address - Fax:215-707-3644
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423477207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010806440001Medicaid
I08219Medicare UPIN
PA1010806440001Medicaid