MEDICARE: JACQUELINE MACGIBBON RD LD

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	133V00000X	Registered Dietitian	DN004129	PA

General Provider Information

NPI Number	:	1578870424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MACGIBBON RD LD

Provider Business Mailing Address
First Line	:	2000 HAMILTON ST
Second Line	:	SUITE 303
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3814
Country	:	US
Telephone Number	:	215-564-4880
Fax Number	:	215-564-4890

Provider Business Practice Location Address
First Line	:	2000 HAMILTON ST
Second Line	:	SUITE 303
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3814
Country	:	US
Telephone Number	:	215-564-4880
Fax Number	:	215-564-4890

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

Provider Enumeration Date	:	09/13/2010
Last Update Date	:	09/13/2010

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