Basic Information
| Provider Information | |||||||||
| NPI: | 1003446261 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIA AFFILIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829641 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191820001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673705296 | ||||||||
| FaxNumber: | 2152303725 | ||||||||
| Practice Location | |||||||||
| Address1: | 599 W STATE ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | DOYLESTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189012567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152306982 | ||||||||
| FaxNumber: | 2152306983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2020 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | EDELSON | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2153452462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIA AFFILIATES | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.