Basic Information
| Provider Information | |||||||||
| NPI: | 1558347625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRISCH | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 UNRUH AVE | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152141094 | ||||||||
| FaxNumber: | 2152141098 | ||||||||
| Practice Location | |||||||||
| Address1: | 7604 CENTRAL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157458989 | ||||||||
| FaxNumber: | 2157459072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD030592E | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0010655470005 | 05 | PA | MEDICAID |