Basic Information
| Provider Information | |||||||||
| NPI: | 1194854851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFELICE | ||||||||
| FirstName: | MAGEE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197230191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S. 11TH STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/16/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA08634500 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | MD437762 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | MD437762 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | MD437762 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 207K00000X | C10010083 | DE | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | MD437762 | PA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 102406939 0001 | 05 | PA | MEDICAID |