Basic Information
| Provider Information | |||||||||
| NPI: | 1437445483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLABORATION HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARDIAC RISK ASSESSMENT AND PREVENTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 552A LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193121635 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 552A LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193121635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 06/28/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6105273438 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD020432E | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.