Healthcare Provider Details

I. General information

NPI: 1942846761
Provider Name (Legal Business Name): STC OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080I0007X
TaxonomyPediatric Clinical & Laboratory Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: GARY CONNER
Title or Position: VP & CFO
Credential:
Phone: 484-628-8181