Provider Demographics
NPI:1144326703
Name:MAKRODIMITRIS, AGISILAOS (PA)
Entity type:Individual
Prefix:
First Name:AGISILAOS
Middle Name:
Last Name:MAKRODIMITRIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RIVER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2439
Mailing Address - Country:US
Mailing Address - Phone:800-355-3818
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:210 E UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2828
Practice Address - Country:US
Practice Address - Phone:202-877-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD970016787OtherRAILROAD MED
MD970016787OtherRAILROAD MED
P16407Medicare UPIN