Provider Demographics
NPI:1255725636
Name:BALCENIUK, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BALCENIUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MARKET ST FL 19
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2926
Mailing Address - Country:US
Mailing Address - Phone:215-481-6836
Mailing Address - Fax:
Practice Address - Street 1:9501 ROOSEVELT BLVD STE 312
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1028
Practice Address - Country:US
Practice Address - Phone:215-331-7001
Practice Address - Fax:215-331-7004
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4810202086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery