Healthcare Provider Details

I. General information

NPI: 1114049566
Provider Name (Legal Business Name): JEREMY DAVID CLOSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CHESTNUT ST 5TH FLOOR
PHILADELPHIA PA
19107-4216
US

IV. Provider business mailing address

833 CHESTNUT STREET SUITE 1402
PHILADELPHIA PA
19107-4405
US

V. Phone/Fax

Practice location:
  • Phone: 267-339-3500
  • Fax: 267-339-3761
Mailing address:
  • Phone: 267-339-7839
  • Fax: 267-339-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT188739
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD435873
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD435873
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: