Provider Demographics
NPI:1053574277
Name:MAMMEN, ANISH GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:ANISH
Middle Name:GEORGE
Last Name:MAMMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4760 UNION DEPOSIT RD
Mailing Address - Street 2:STE 100
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-3744
Mailing Address - Country:US
Mailing Address - Phone:717-545-5099
Mailing Address - Fax:717-545-9979
Practice Address - Street 1:310 E 24TH ST
Practice Address - Street 2:APT 1L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4012
Practice Address - Country:US
Practice Address - Phone:617-513-9508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD472422207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program