Basic Information
| Provider Information | |||||||||
| NPI: | 1336382027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2159232275 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2159232275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2009 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD444134 | PA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 25MA09973500 | NJ | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 2015-00289 | NC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 102843872 | 05 | PA | MEDICAID | 06649466 | 05 | NJ | MEDICAID | 1336382027 | 05 | NC | MEDICAID | NC2463 | 05 | SC | MEDICAID |