Healthcare Provider Details

I. General information

NPI: 1932197563
Provider Name (Legal Business Name): TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 73 N ONE GREENTREE CENTER
MARLTON NJ
08053
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 856-596-0906
  • Fax: 856-596-6918
Mailing address:
  • Phone: 856-596-0609
  • Fax: 856-596-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. TRACEY J CLARK
Title or Position: DIRECTOR, GOVERNMENT AND PAYER RELA
Credential:
Phone: 856-596-0906