Healthcare Provider Details

I. General information

NPI: 1033359542
Provider Name (Legal Business Name): JEFFERSONVILLE FAMILY AND GERIATRIC MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WEST GERMANTOWN PIKE SUITE 155
EAST NORRITON PA
19401-1383
US

IV. Provider business mailing address

190 W GERMANTOWN PIKE SUITE 155
EAST NORRITON PA
19401-1385
US

V. Phone/Fax

Practice location:
  • Phone: 610-277-9040
  • Fax: 610-277-7890
Mailing address:
  • Phone: 610-277-9040
  • Fax: 610-277-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS006150L
License Number StatePA

VIII. Authorized Official

Name: DR. WILLIAM R. DICKERMAN
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 610-277-9040