Healthcare Provider Details

I. General information

NPI: 1801323258
Provider Name (Legal Business Name): ALYSSA MARY YEAGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 07/21/2022
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH ST
PHILADELPHIA PA
19107-4824
US

IV. Provider business mailing address

1349 N PALETHORP ST
PHILADELPHIA PA
19122-4511
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 856-217-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM470076
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: