Provider Demographics
NPI:1023105798
Name:MAMENISKIS, ALGIRD R (MD, FACS)
Entity type:Individual
Prefix:
First Name:ALGIRD
Middle Name:R
Last Name:MAMENISKIS
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S 17TH ST
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6231
Mailing Address - Country:US
Mailing Address - Phone:215-732-3340
Mailing Address - Fax:215-732-3160
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:215-732-3340
Practice Address - Fax:215-732-3160
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041644-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA588196Medicare ID - Type Unspecified
PAF85924Medicare UPIN