Provider Demographics
NPI:1629160742
Name:DR. MAX E. MERCADO PRACTICE, LLC
Entity Type:Organization
Organization Name:DR. MAX E. MERCADO PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-289-4434
Mailing Address - Street 1:1331 E WYOMING AVE
Mailing Address - Street 2:SUITE 3090
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3808
Mailing Address - Country:US
Mailing Address - Phone:215-289-4434
Mailing Address - Fax:215-289-7442
Practice Address - Street 1:1331 E WYOMING AVE
Practice Address - Street 2:SUITE 3090
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3808
Practice Address - Country:US
Practice Address - Phone:215-289-4434
Practice Address - Fax:215-289-7442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019063200001Medicaid
PA125821Medicare PIN