Basic Information
| Provider Information | |||||||||
| NPI: | 1770995482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINIC | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E. ERIE AVENUE | ||||||||
| Address2: | ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191341043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 160 E. ERIE AVENUE | ||||||||
| Address2: | ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 05/28/2018 | ||||||||
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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 | 208000000X | OT016053 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OS018584 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.