Provider Demographics
NPI:1326442542
Name:MAHAUTMR, PENDEN PATTI (MD)
Entity Type:Individual
Prefix:
First Name:PENDEN
Middle Name:PATTI
Last Name:MAHAUTMR
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 1:1001 CHESTERBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-3805
Mailing Address - Country:US
Mailing Address - Phone:610-576-7636
Mailing Address - Fax:334-613-3685
Practice Address - Street 1:1840 SOUTH STREET
Practice Address - Street 2:TUTTLEMAN BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-7411
Practice Address - Country:US
Practice Address - Phone:215-893-6200
Practice Address - Fax:215-893-6215
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD459539207Q00000X
ALL.3947R390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program