Provider Demographics
NPI:1487655445
Name:EISENMAN, MALLORY LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:LYNN
Last Name:EISENMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RITTENHOUSE SQ
Mailing Address - Street 2:SUITE C3
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5767
Mailing Address - Country:US
Mailing Address - Phone:215-735-3668
Mailing Address - Fax:215-735-1838
Practice Address - Street 1:1900 RITTENHOUSE SQ
Practice Address - Street 2:SUITE C3
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5767
Practice Address - Country:US
Practice Address - Phone:215-735-3668
Practice Address - Fax:215-735-1838
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC0021671213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0480001090OtherRAILROAD MEDICARE
000492696OtherBLUECROSS
402696OtherHIGHMARK
PA010346300001Medicaid
000492696OtherBLUECROSS
PA402696Medicare ID - Type Unspecified
402696OtherHIGHMARK