MEDICARE: ROMAN DYKYJ JR MD PC

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	261QP2300X	Primary Care Clinic/Center	MD027187E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0054192000	OTHER	PA	INDEPENDENT BLUE CROSS
2	0054192001	OTHER	PA	KEYSTONE HPE
3	2061288	OTHER	PA	AETNA
4	A00995	OTHER	PA	AMERIHEALTH ADMINISTRATOR

General Provider Information

NPI Number	:	1689850901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROMAN DYKYJ JR MD PC

Provider Business Mailing Address
First Line	:	8151 REVERE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3002
Country	:	US
Telephone Number	:	215-624-6855
Fax Number	:

Provider Business Practice Location Address
First Line	:	8151 REVERE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3002
Country	:	US
Telephone Number	:	215-624-6855
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROMAN DYKYJ JR.
Credential	:	MD
Telephone Number	:	215-624-3000

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	01/21/2008

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