Healthcare Provider Details

I. General information

NPI: 1568408748
Provider Name (Legal Business Name): GARY W DORSHIMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 DELANCEY STREET
PHILADELPHIA PA
19106
US

IV. Provider business mailing address

727 DELANCEY ST SUITE 1A
PHILADELPHIA PA
19106-4002
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-3523
  • Fax: 215-829-6023
Mailing address:
  • Phone: 215-829-3016
  • Fax: 215-829-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD027094E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD027094E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: