Healthcare Provider Details

I. General information

NPI: 1831104496
Provider Name (Legal Business Name): BECKY A SOUDER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 INDUSTRIAL BLVD SUITE 103
PAOLI PA
19301-1632
US

IV. Provider business mailing address

11 INDUSTRIAL BLVD SUITE 103
PAOLI PA
19301-1632
US

V. Phone/Fax

Practice location:
  • Phone: 610-786-3200
  • Fax: 610-786-3208
Mailing address:
  • Phone: 610-786-3200
  • Fax: 610-786-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS010701L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: