Healthcare Provider Details

I. General information

NPI: 1457117566
Provider Name (Legal Business Name): PATRICK HIRST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 WALNUT ST
PHILADELPHIA PA
19107-5211
US

IV. Provider business mailing address

1269 N DOVER ST
PHILADELPHIA PA
19121-4522
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6215
  • Fax:
Mailing address:
  • Phone: 412-628-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberSP028986
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: