Provider Demographics
NPI:1710912332
Name:SCADUTO, PHILIP MARK (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:MARK
Last Name:SCADUTO
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:PO BOX 95000 LB# 7550
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7550
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:223 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005
Practice Address - Country:US
Practice Address - Phone:973-335-8656
Practice Address - Fax:973-335-8986
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04449300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C60256Medicare UPIN
484505POSMedicare ID - Type Unspecified