Provider Demographics
NPI:1265412753
Name:LIEM, MARINA DEWI (MD)
Entity type:Individual
Prefix:DR
First Name:MARINA
Middle Name:DEWI
Last Name:LIEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GREENWOOD AVE STE 150
Mailing Address - Street 2:TRISTATE IMAGING
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046
Mailing Address - Country:US
Mailing Address - Phone:215-244-3070
Mailing Address - Fax:215-638-9041
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1436
Practice Address - Country:US
Practice Address - Phone:215-612-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042422E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0120634Medicaid
PA001815520Medicaid
PA453678Medicare PIN
NJ0120634Medicaid
F47021Medicare UPIN
PA453678Medicare ID - Type Unspecified
PA001815520Medicaid