Basic Information
| Provider Information | |||||||||
| NPI: | 1609883289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIPOLLE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 783311 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
| FaxNumber: | 4848840699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 S CEDAR CREST BLVD STE 308 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104021350 | ||||||||
| FaxNumber: | 6104021356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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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 | 208600000X | C10008548 | DE | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | C10008548 | DE | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | MD049909L | PA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | MD049909L | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 1609883289 | 05 | DE | MEDICAID |