Provider Demographics
NPI:1770583064
Name:MORAN, MARK E (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MORAN
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 1:1204 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-4119
Mailing Address - Country:US
Mailing Address - Phone:610-628-2022
Mailing Address - Fax:610-628-4966
Practice Address - Street 1:1204 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-4119
Practice Address - Country:US
Practice Address - Phone:610-628-2022
Practice Address - Fax:610-628-2022
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006169L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011964500002Medicaid
PA0412930001Medicare NSC
PAE52972Medicare UPIN
PA0011964500002Medicaid