Provider Demographics
NPI:1831154764
Name:VANDERBILT, MARK DAVID (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:VANDERBILT
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 1:4800 FRIENDSHIP AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-1722
Mailing Address - Country:US
Mailing Address - Phone:412-359-6656
Mailing Address - Fax:412-359-6653
Practice Address - Street 1:4800 FRIENDSHIP AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1722
Practice Address - Country:US
Practice Address - Phone:412-359-6656
Practice Address - Fax:412-359-6653
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 046732 L207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012839580001Medicaid
WV217529000Medicaid
OH2199857Medicaid
E35509Medicare UPIN
OH2199857Medicaid
PA722734KK2Medicare PIN