Basic Information
| Provider Information | |||||||||
| NPI: | 1275522120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALD | ||||||||
| FirstName: | JOYCE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | EAST PAVILION, 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
| FaxNumber: | 2156150829 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | EAST PAVILION, 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
| FaxNumber: | 2156150829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 09/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | OS008299L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | OS008299L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RA0001X | OS008299L | PA | Y |
ID Information
| ID | Type | State | Issuer | Description | 0017549800001 | 05 | PA | MEDICAID |