Provider Demographics
NPI:1801899281
Name:LAVINE, MARC A (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:LAVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-632-8882
Mailing Address - Fax:215-632-2232
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:STE 305
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1436
Practice Address - Country:US
Practice Address - Phone:215-632-8882
Practice Address - Fax:215-632-2232
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD070920L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017988220001Medicaid
PA127376OtherHIGHMARK BLUE SHIELD
PA0800550000OtherKEYSTONE IBC
PAP01043213OtherRAILROAD MEDICARE
PA232691968OtherHEALTH PARTNERS
PA30106257OtherKEYSTONE MERCY
PA8317363OtherAETNA
PA0800550000OtherKEYSTONE IBC
PA232691968OtherHEALTH PARTNERS
PA0017988220001Medicaid