Healthcare Provider Details

I. General information

NPI: 1134127426
Provider Name (Legal Business Name): DELAWARE VALLEY MEDICAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRESIDENTIAL BLVD 4TH FLOOR
BALA CYNWYD PA
19004-1108
US

IV. Provider business mailing address

100 PRESIDENTIAL BLVD 4TH FLOOR
BALA CYNWYD PA
19004-1108
US

V. Phone/Fax

Practice location:
  • Phone: 610-664-2122
  • Fax: 610-664-2315
Mailing address:
  • Phone: 610-664-2122
  • Fax: 610-664-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number01161501
License Number StatePA

VIII. Authorized Official

Name: MS. DELORES DEBRUCE
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 610-949-7132