Basic Information
| Provider Information | |||||||||
| NPI: | 1508830365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FELLHEIMER | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 EAST OLNEY VE | ||||||||
| Address2: | SUITE 505 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152542630 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 NEW YORK DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156437331 | ||||||||
| FaxNumber: | 2156540741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD024450E | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0016188800009 | 05 | PA | MEDICAID |