Basic Information
Provider Information | |||||||||
NPI: | 1043467384 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WANG | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | LY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 833 CHESTNUT ST STE 520 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003219999 | ||||||||
FaxNumber: | 2673393761 | ||||||||
Practice Location | |||||||||
Address1: | 825 OLD LANCASTER RD STE 100 | ||||||||
Address2: |   | ||||||||
City: | BRYN MAWR | ||||||||
State: | PA | ||||||||
PostalCode: | 190103234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2673393558 | ||||||||
FaxNumber: | 2673393763 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2008 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A97865 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0106X | 307138 | NY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | ME152694 | FL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 25MA08750000 | NJ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | MD439395 | PA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
No ID Information.