Provider Demographics
NPI:1578528410
Name:RADZIEWICZ, MARK M (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:RADZIEWICZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:WILKES BARRE GENEAL HOSPITAL
Practice Address - Street 2:575 N. RIVER STREET
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18764-0001
Practice Address - Country:US
Practice Address - Phone:570-552-4450
Practice Address - Fax:570-552-4455
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS009207L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001714170Medicaid
PA413839Medicare ID - Type Unspecified
PA001714170Medicaid