Basic Information
| Provider Information | |||||||||
| NPI: | 1407010143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISTANCHO PIMIENTO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 MARKET STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157466700 | ||||||||
| FaxNumber: | 2157465155 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 MARKET STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157466700 | ||||||||
| FaxNumber: | 2157465155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MT193855 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | MT193855 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | MD443666 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.