Healthcare Provider Details

I. General information

NPI: 1720125701
Provider Name (Legal Business Name): REBECCA S WITHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE SUITE 237 PAOLI MOB III
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W LANCASTER AVE SUITE 237 PAOLI MOB III
PAOLI PA
19301-1763
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1212
  • Fax: 484-565-8881
Mailing address:
  • Phone: 484-565-1212
  • Fax: 484-565-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD036577E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberMD036577E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: