Basic Information
| Provider Information | |||||||||
| NPI: | 1235663881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEPHIS | ||||||||
| FirstName: | NICOLAUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159269022 | ||||||||
| FaxNumber: | 2152268286 | ||||||||
| Practice Location | |||||||||
| Address1: | 7600 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157282276 | ||||||||
| FaxNumber: | 2152144119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2017 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 66948 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | TMD005234 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.