Healthcare Provider Details

I. General information

NPI: 1831353879
Provider Name (Legal Business Name): PENNSYLVANIA PHLEBOLOGY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 EAGLEVIEW BLVD STE 303
EXTON PA
19341-1159
US

IV. Provider business mailing address

2015 SPRING RD STE 300
OAK BROOK IL
60523-3944
US

V. Phone/Fax

Practice location:
  • Phone: 610-321-2615
  • Fax: 610-321-2616
Mailing address:
  • Phone: 630-725-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: CYNTHIA JONES
Title or Position: CREDENTIALING
Credential:
Phone: 630-725-2737