Provider Demographics
NPI:1992967624
Name:INFECTIOUS DISEASES MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:INFECTIOUS DISEASES MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-237-5816
Mailing Address - Street 1:1503 LANSDOWNE AVE.
Mailing Address - Street 2:SUITE 3010
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1308
Mailing Address - Country:US
Mailing Address - Phone:610-237-5816
Mailing Address - Fax:
Practice Address - Street 1:1503 LANSDOWNE AVE.
Practice Address - Street 2:SUITE 3010
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1308
Practice Address - Country:US
Practice Address - Phone:610-237-5816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025745E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009816070002Medicaid