Healthcare Provider Details

I. General information

NPI: 1740206226
Provider Name (Legal Business Name): TYSON FAMILY MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 TYSON AVE
PHILADELPHIA PA
19149-1415
US

IV. Provider business mailing address

2831 TYSON AVE
PHILADELPHIA PA
19149-1415
US

V. Phone/Fax

Practice location:
  • Phone: 267-350-5575
  • Fax: 215-624-0874
Mailing address:
  • Phone: 267-350-5575
  • Fax: 215-624-0874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS005343-L
License Number StatePA

VIII. Authorized Official

Name: DR. DAVID M PUDLES
Title or Position: OWNER
Credential: D.O
Phone: 267-350-5575