Healthcare Provider Details

I. General information

NPI: 1578683017
Provider Name (Legal Business Name): EILEEN AMY BAZELON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 CITY AVE D-120
PHILA PA
19131-2908
US

IV. Provider business mailing address

3900 CITY AVE D-120
PHILA PA
19131-2908
US

V. Phone/Fax

Practice location:
  • Phone: 215-477-3330
  • Fax: 215-477-3362
Mailing address:
  • Phone: 215-477-3330
  • Fax: 215-477-3362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD013268E
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: