Healthcare Provider Details

I. General information

NPI: 1952640187
Provider Name (Legal Business Name): PENN INTEGRATIVE MEDICAL AND DENTAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7130 RISING SUN AVE
PHILADELPHIA PA
19111-3957
US

IV. Provider business mailing address

7130 RISING SUN AVE
PHILADELPHIA PA
19111-3957
US

V. Phone/Fax

Practice location:
  • Phone: 215-821-2305
  • Fax: 215-220-2600
Mailing address:
  • Phone: 215-821-2305
  • Fax: 215-220-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JULIAN SANON
Title or Position: PRESIDENT / OWNER
Credential: M.D.
Phone: 215-821-2305