Provider Demographics
NPI:1588999585
Name:MARK, MINA E (MD)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:E
Last Name:MARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:500 S BROAD ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1613
Mailing Address - Country:US
Mailing Address - Phone:215-685-6769
Mailing Address - Fax:215-685-6732
Practice Address - Street 1:131 E CHELTEN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2153
Practice Address - Country:US
Practice Address - Phone:215-685-5701
Practice Address - Fax:215-685-5748
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD041619L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01553893Medicaid
PAMA790738Medicare PIN
PAF87873Medicare UPIN