Healthcare Provider Details

I. General information

NPI: 1740964741
Provider Name (Legal Business Name): CAROLINE A CONLON MB BCH BAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

3500 N BROAD ST RM 1A
PHILADELPHIA PA
19140-4106
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-3807
  • Fax:
Mailing address:
  • Phone: 215-707-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License NumberMD487992
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberLT000971
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: