Healthcare Provider Details

I. General information

NPI: 1316000805
Provider Name (Legal Business Name): JESSE MICHAEL CIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CHESTNUT ST
PHILADELPHIA PA
19107-3612
US

IV. Provider business mailing address

132 SOUTH 10TH STREET 480 MAIN BUILDING
PHILADELPHIA PA
19107
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-8900
  • Fax: 215-955-5245
Mailing address:
  • Phone: 215-955-8900
  • Fax: 215-955-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD436852
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: