Healthcare Provider Details

I. General information

NPI: 1376988410
Provider Name (Legal Business Name): GREAT VALLEY OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 THOMAS JONES WAY MAIN LINE HEALTH CTR SUITE 210
EXTON PA
19341-2553
US

IV. Provider business mailing address

495 THOMAS JONES WAY MAIN LINE HEALTH CTR SUITE 210
EXTON PA
19341-2553
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-8550
  • Fax: 610-280-1569
Mailing address:
  • Phone: 484-565-8550
  • Fax: 610-280-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CAROL COLDREN
Title or Position: PHYSICIAN
Credential: MD
Phone: 484-565-8550