Basic Information
| Provider Information | |||||||||
| NPI: | 1023438223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLLER | ||||||||
| FirstName: | ANNAMARIE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PENN SQUARE EAST | ||||||||
| Address2: | CHCA GENERAL PEDIATRICS | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259200 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 E MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193804412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104315376 | ||||||||
| FaxNumber: | 6104315527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2014 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS018794 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1033657140001 | 05 | PA | MEDICAID |