Provider Demographics
NPI:1629042585
Name:COREY, MARK JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:COREY
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:705-887-2239
Practice Address - Fax:570-887-3285
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216573-1207Q00000X
PAMD-066447L207Q00000X
PAMD066447L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
PA0017395360003Medicaid
NY080173598OtherRR MEDICARE PIN
PAP00402922OtherRR MEDICARE PIN
NY01927182Medicaid
PAGU039851OtherMEDICARE GROUP
PA025644N86Medicare PIN
G89356Medicare UPIN
NYCC2108Medicare ID - Type Unspecified