Provider Demographics
NPI:1639132145
Name:MUDRICK, MARYLYN ANN (MD029229E)
Entity Type:Individual
Prefix:
First Name:MARYLYN
Middle Name:ANN
Last Name:MUDRICK
Suffix:
Gender:F
Credentials:MD029229E
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303A EDGMOUT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2801
Mailing Address - Country:US
Mailing Address - Phone:610-872-0565
Mailing Address - Fax:610-872-4478
Practice Address - Street 1:3303A EDGMOUT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2801
Practice Address - Country:US
Practice Address - Phone:610-872-0565
Practice Address - Fax:610-872-4478
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029229E208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01500441Medicaid
5023294OtherAETNA
0554265001OtherKEYSTONE BA ST
5023294OtherAETNA
B41974Medicare UPIN