Healthcare Provider Details

I. General information

NPI: 1487001996
Provider Name (Legal Business Name): PROSPECT HEALTH ACCESS NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD GROUND FLOOR
CHESTER PA
19013-3902
US

IV. Provider business mailing address

1 MEDICAL CENTER BLVD GROUND FLOOR
CHESTER PA
19013-3902
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-7410
  • Fax: 610-490-0925
Mailing address:
  • Phone: 610-619-7410
  • Fax: 610-490-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT JON ELDERS
Title or Position: SECRETARY
Credential:
Phone: 714-788-1249