MEDICARE: DR. ALBERT T. DERIVAN M.D.

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	2084P0804X	Child & Adolescent Psychiatry Physician	MD034282E	PA

General Provider Information

NPI Number	:	1235135294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALBERT T. DERIVAN M.D.

Provider Business Mailing Address
First Line	:	23438 SHANNONDELL DR
Second Line	:
City	:	AUDUBON
State	:	PA
Zip	:	19403-5675
Country	:	US
Telephone Number	:	215-260-1721
Fax Number	:	610-382-6813

Provider Business Practice Location Address
First Line	:	23438 SHANNONDELL DR
Second Line	:
City	:	AUDUBON
State	:	PA
Zip	:	19403-5675
Country	:	US
Telephone Number	:	215-260-1721
Fax Number	:	610-382-6813

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	04/01/2021

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