MEDICARE: MR. WILLIAM HENRY STALLINGS JR. RD LDN CSSD

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	DN002543	PA

General Provider Information

NPI Number	:	1780797563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM HENRY STALLINGS JR. RD LDN CSSD

Provider Business Mailing Address
First Line	:	2824 COTTMAN AVE
Second Line	:	SUITE 11
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1400
Country	:	US
Telephone Number	:	215-333-6126
Fax Number	:	215-333-6127

Provider Business Practice Location Address
First Line	:	2824 COTTMAN AVE
Second Line	:	SUITE 11
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1400
Country	:	US
Telephone Number	:	215-333-6126
Fax Number	:	215-333-6127

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	12/06/2012

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