Healthcare Provider Details

I. General information

NPI: 1962803031
Provider Name (Legal Business Name): SUBURBAN MULTISPECIALTY LIMITED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BELMONT AVENUE SUITE 416
BALA CYNWYD PA
19004-1607
US

IV. Provider business mailing address

1 BELMONT AVENUE SUITE 416
BALA CYNWYD PA
19004-1607
US

V. Phone/Fax

Practice location:
  • Phone: 610-667-4080
  • Fax: 610-667-2748
Mailing address:
  • Phone: 610-667-4080
  • Fax: 610-667-2748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS-009268L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberOS.015962
License Number StatePA

VIII. Authorized Official

Name: MRS. DINA JEAN DUBROW
Title or Position: PRACTICE MANAGER
Credential:
Phone: 610-667-4080