Healthcare Provider Details

I. General information

NPI: 1447256755
Provider Name (Legal Business Name): JEFFREY L WANNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8302 OLD YORK RD BRIARHOUSE
ELKINS PARK PA
19027-1522
US

IV. Provider business mailing address

8302 OLD YORK RD BRIARHOUSE
ELKINS PARK PA
19027-1522
US

V. Phone/Fax

Practice location:
  • Phone: 215-885-8550
  • Fax: 215-885-8870
Mailing address:
  • Phone: 215-885-8550
  • Fax: 215-885-8870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME166373
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD065642L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: