Basic Information
| Provider Information | |||||||||
| NPI: | 1740784123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIA AFFILIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | DOYLESTOWN HEALTH WOUND CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829641 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191820001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673705296 | ||||||||
| FaxNumber: | 2152303725 | ||||||||
| Practice Location | |||||||||
| Address1: | 595 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | DOYLESTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189012554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673705296 | ||||||||
| FaxNumber: | 2678851757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDELSON | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2153452462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIA AFFILIATES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.