Basic Information
| Provider Information | |||||||||
| NPI: | 1912983552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MABINE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | JUNIOUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | 7TH FLOOR OUT PATIENT BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073008 | ||||||||
| FaxNumber: | 2157071387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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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 | 207V00000X | MD023436E | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000975172 | 05 | PA | MEDICAID | 0052784000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 0097517210 | 01 | PA | AMERICHOICE | OTHER | 1036665 | 01 | PA | KEYSTONE MERCY HEALTH | OTHER | 4590 | 01 | PA | BRAVO HEALTH | OTHER | 4216207 | 01 | PA | AETNA PPO | OTHER | 519073 | 01 | PA | HEALTH AMERICA | OTHER | 059989 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 3211325 | 01 | PA | AETNA HMO | OTHER |