Healthcare Provider Details

I. General information

NPI: 1821103995
Provider Name (Legal Business Name): KISHA VANTERPOOL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

5410 MARYLAND WAY SUITE 300
BRENTWOOD TN
37027-5064
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-9403
  • Fax: 215-225-1698
Mailing address:
  • Phone: 615-377-5652
  • Fax: 888-241-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD429577
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036139805
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD429577
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: