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Specialty details in registry · Philadelphia, PA

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At a glance

2036 Fairmount Ave, Philadelphia, PA 19130-2602

NPPES record updated Jan 24, 2017. Public records can lag behind changes at a practice.

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Practice location

2036 Fairmount Ave
Philadelphia, PA 19130-2602

Professional details: NPI, taxonomy & registry record

NPI1861939175

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Registry details

Primary taxonomy: Specialty details in registry
Taxonomy code: 332BC3200X
Enumeration date: Jan 24, 2017
Record updated: Jan 24, 2017

More registry details

Provider type: Organization · Type 2

Reported taxonomies and licenses

Specialty details in registry

332BC3200X · Primary

License numbers and credentials are reported to NPPES; HCPList does not independently verify them.

Practice location

2036 Fairmount Ave
Philadelphia, PA 19130-2602

Phone: (215) 769-1500

Mailing address

2036 FAIRMOUNT AVE

PHILADELPHIA, PA 191302602

Source: NPPES Source through Oct 18, 2026An NPI does not verify licensure or credentials.

Information may be outdated or incomplete. Confirm details directly with the practice. HCPList is an independent directory and is not affiliated with CMS.

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