Provider Demographics
NPI:1245309103
Name:ANDERSON, MARK B (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:551-996-2880
Mailing Address - Fax:551-996-3984
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-8270
Practice Address - Fax:215-456-3533
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD445899208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ330005347OtherRR MCR PTAN
NJ8328102Medicaid
NJ042805NAHMedicare PIN
NJ042805M4EMedicare PIN
NJ330005347OtherRR MCR PTAN
PA042805Medicare PIN