Provider Demographics
NPI:1700944436
Name:BURRELL, MARK M (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:BURRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:MANHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:17545-2408
Mailing Address - Country:US
Mailing Address - Phone:717-665-7791
Mailing Address - Fax:
Practice Address - Street 1:8 N CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:MANHEIM
Practice Address - State:PA
Practice Address - Zip Code:17545-2408
Practice Address - Country:US
Practice Address - Phone:717-665-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003209L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA231934347OtherEMP ID #
PAD99650Medicare UPIN