Healthcare Provider Details

I. General information

NPI: 1730445198
Provider Name (Legal Business Name): FRONT STREET FAMILY MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W FRONT ST
MEDIA PA
19063-3232
US

IV. Provider business mailing address

112 W FRONT ST
MEDIA PA
19063-3232
US

V. Phone/Fax

Practice location:
  • Phone: 610-566-1881
  • Fax: 610-566-4776
Mailing address:
  • Phone: 610-566-1881
  • Fax: 610-566-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberOS008967L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS008967L
License Number StatePA

VIII. Authorized Official

Name: DR. RICHARD M DIMONTE JR.
Title or Position: PRESIDENT
Credential: D.O.
Phone: 610-566-1881