Basic Information
| Provider Information | |||||||||
| NPI: | 1831154764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERBILT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 FRIENDSHIP AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152241722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123596656 | ||||||||
| FaxNumber: | 4123596653 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 FRIENDSHIP AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152241722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123596656 | ||||||||
| FaxNumber: | 4123596653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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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 | 207RC0200X | MD 046732 L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0012839580001 | 05 | PA | MEDICAID | 217529000 | 05 | WV | MEDICAID | 2199857 | 05 | OH | MEDICAID |