Healthcare Provider Details

I. General information

NPI: 1003683517
Provider Name (Legal Business Name): CAROL BUHRMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

5121 IRVING ST
PHILADELPHIA PA
19139-4114
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-5800
  • Fax:
Mailing address:
  • Phone: 215-490-5143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number1067236
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: