Basic Information
| Provider Information | |||||||||
| NPI: | 1740260017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOHN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157077237 | ||||||||
| FaxNumber: | 2157079389 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157077237 | ||||||||
| FaxNumber: | 2157079389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
| 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 | 2085R0202X | MD032981E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA08164200 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | MD032981E | 01 | PA | HEALTH PARTNERS | OTHER | 120683 | 01 | PA | PHCS | OTHER | 231955165 | 01 | PA | AETNA USHC | OTHER | 231955165 | 01 | PA | INTERGROUP SERVICES | OTHER | P00398000 | 01 | NJ | RRML | OTHER | 001114463 | 01 | PA | AMERICHOICE OF PA | OTHER | 0011144630004 | 05 | PA | MEDICAID | 1031977 | 01 | PA | KEYSTONE MERCY | OTHER | 512306 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | PA7584 | 01 | PA | HEALTHNET | OTHER | 0110323000 | 01 | PA | IBC KHPE | OTHER | 300025834 | 01 | PA | RAILROAD MEDICARE | OTHER | 0127175 | 05 | NJ | MEDICAID | 001114463 | 05 | PA | MEDICAID | MD032981E | 01 | PA | PA LICENSE | OTHER |