Healthcare Provider Details

I. General information

NPI: 1881089746
Provider Name (Legal Business Name): XIMENA JORDAN BRUNO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE STREET
PHILADELPHIA PA
19104-4204
US

IV. Provider business mailing address

3400 SPRUCE STREET
PHILADELPHIA PA
19104-4204
US

V. Phone/Fax

Practice location:
  • Phone: 215-615-0063
  • Fax: 215-349-8144
Mailing address:
  • Phone: 215-615-0063
  • Fax: 215-349-8144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD474997
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: