Provider Demographics
NPI:1366439705
Name:MARDINI, ISSAM A (MD)
Entity Type:Individual
Prefix:
First Name:ISSAM
Middle Name:A
Last Name:MARDINI
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 1:3400 SPRUCE ST
Mailing Address - Street 2:HUP-DULLES 6, ANESTHESIOLOGY DEPT
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:610-416-4145
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:HUP-DULLES 6, ANESTHESIOLOGY DEPT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:610-416-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060309L207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001753310Medicaid
PA001753310Medicaid
PAG93705Medicare UPIN