Provider Demographics
NPI:1205891140
Name:BORENSTEIN, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:BORENSTEIN
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 1:40 VALLEY STREAM PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:484-924-0053
Practice Address - Street 1:250 E DAY RD STE 300
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3471
Practice Address - Country:US
Practice Address - Phone:574-273-6787
Practice Address - Fax:574-968-0882
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0562682085R0204X, 2085R0202X
IN01079540A2085R0204X
FLME1117962085R0204X, 2085R0202X
MO20230500792085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA133195677AMedicaid
GA30BDMCLMedicare ID - Type Unspecified
GAD92022Medicare UPIN
GA133195677AMedicaid