Basic Information
Provider Information | |||||||||
NPI: | 1508813445 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEISS | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 SPRUCE ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 19104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2153498310 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3400 SPRUCE STREET | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2153498310 | ||||||||
FaxNumber: | 8438054040 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 11/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 19090 | SC | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | MD441213 | PA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | T31043 | 05 | SC |   | MEDICAID |