Healthcare Provider Details

I. General information

NPI: 1114041514
Provider Name (Legal Business Name): POTTSTOWN MEDICAL SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 N. WALNUT ST
BOYERTOWN PA
19512
US

IV. Provider business mailing address

23 N. WALNUT STREET
BOYERTOWN PA
19512
US

V. Phone/Fax

Practice location:
  • Phone: 610-367-2259
  • Fax: 610-367-0505
Mailing address:
  • Phone: 610-367-2259
  • Fax: 610-367-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS008215L
License Number StatePA

VIII. Authorized Official

Name: SHANA M ENOCHS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 610-327-4200