MEDICARE: DR. JAN NEIL WIDERMAN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	OS004029L	PA

General Provider Information

NPI Number	:	1023197977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAN NEIL WIDERMAN D.O.

Provider Business Mailing Address
First Line	:	10800 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3302
Country	:	US
Telephone Number	:	215-934-6777
Fax Number	:	215-934-6787

Provider Business Practice Location Address
First Line	:	10800 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3302
Country	:	US
Telephone Number	:	215-934-6777
Fax Number	:	215-934-6787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	02/20/2013

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