1043311764 NPI number — WYNCOTE PHYSICAL MEDICINE & DIAGNOSTIC PC

Table of content: (NPI 1043311764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043311764 NPI number — WYNCOTE PHYSICAL MEDICINE & DIAGNOSTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYNCOTE PHYSICAL MEDICINE & DIAGNOSTIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043311764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 WASHINGTON LN
Provider Second Line Business Mailing Address:
STE 13C
Provider Business Mailing Address City Name:
WYNCOTE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19095-1400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-887-5030
Provider Business Mailing Address Fax Number:
215-887-5525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 WASHINGTON LN
Provider Second Line Business Practice Location Address:
STE 13C
Provider Business Practice Location Address City Name:
WYNCOTE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19095-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-887-5030
Provider Business Practice Location Address Fax Number:
215-887-5525
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TABUENA
Authorized Official First Name:
AMELIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ATTENDING PHYSICIAN
Authorized Official Telephone Number:
215-887-5030

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  MD039601L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com