Healthcare Provider Details

I. General information

NPI: 1225650930
Provider Name (Legal Business Name): THE MODERN COUNTRY DOCTOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 INDUSTRIAL BLVD STE D
PAOLI PA
19301-1601
US

IV. Provider business mailing address

23 INDUSTRIAL BLVD STE D
PAOLI PA
19301-1601
US

V. Phone/Fax

Practice location:
  • Phone: 610-890-8522
  • Fax: 484-568-4748
Mailing address:
  • Phone: 610-890-8522
  • Fax: 484-568-4748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DENNIS FAITH
Title or Position: OWNER
Credential: MD
Phone: 610-890-8522