Provider Demographics
NPI:1841279445
Name:PASSARELLA, MARK HAROLD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:HAROLD
Last Name:PASSARELLA
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 1:155 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8607
Mailing Address - Country:US
Mailing Address - Phone:434-295-0184
Mailing Address - Fax:434-295-2463
Practice Address - Street 1:155 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8607
Practice Address - Country:US
Practice Address - Phone:434-295-0184
Practice Address - Fax:434-295-2463
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234456208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
386744OtherANTHEM/BLUE CROSS
386744OtherANTHEM/BLUE CROSS
H84085Medicare UPIN
001648U23Medicare PIN