Healthcare Provider Details

I. General information

NPI: 1659392926
Provider Name (Legal Business Name): KATHLEEN E. SQUIRES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CHESTNUT ST SUITE 1020
PHILADELPHIA PA
19107-4310
US

IV. Provider business mailing address

1015 CHESTNUT ST SUITE 1020
PHILADELPHIA PA
19107-4310
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7785
  • Fax: 215-955-9362
Mailing address:
  • Phone: 215-955-7785
  • Fax: 215-955-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD029556E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD029556E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: