Healthcare Provider Details

I. General information

NPI: 1265060164
Provider Name (Legal Business Name): MAXWELL AMBROSINO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE ST
PHILADELPHIA PA
19107-6192
US

IV. Provider business mailing address

800 SPRUCE ST 1 PINE WEST
PHILADELPHIA PA
19107-6130
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-5410
  • Fax:
Mailing address:
  • Phone: 215-829-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS022918
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: