Healthcare Provider Details

I. General information

NPI: 1376101410
Provider Name (Legal Business Name): MICHAEL WALTER SZYMENDERA RND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 N BROAD ST
PHILADELPHIA PA
19140-4160
US

IV. Provider business mailing address

3551 N BROAD ST
PHILADELPHIA PA
19140-4160
US

V. Phone/Fax

Practice location:
  • Phone: 215-430-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN002725
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: