Provider Demographics
NPI:1083698229
Name:OBENRADER, MARK FRANCIS (MD PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FRANCIS
Last Name:OBENRADER
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-540-8408
Mailing Address - Fax:215-540-8418
Practice Address - Street 1:515 PENNSYLVANIA AVE
Practice Address - Street 2:2ND FL SUITE A
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3314
Practice Address - Country:US
Practice Address - Phone:215-540-8408
Practice Address - Fax:215-540-8418
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025847E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007057785Medicaid
PA110115445OtherRAILROAD MEDICARE
PAP00360693OtherRAILROAD MEDICARE TPI
PA12212OtherBRAVO HEALTH
PA445439OtherHIGHMARK BLUE SHIELD
PA3725226OtherAETNA HMO
PA3Y7167OtherHEALTH NET
PA4104719OtherAETNA PPO
PA30019076OtherKEYSTONE MERCY HEALTH PL
PA0047316000OtherINDEPENDENCE BLUE CROSS
PA3725226OtherAETNA HMO
PA3Y7167OtherHEALTH NET