Healthcare Provider Details

I. General information

NPI: 1104470764
Provider Name (Legal Business Name): POPLAR MEDICAL GROUP,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W GIRARD AVE
PHILADELPHIA PA
19130-1400
US

IV. Provider business mailing address

PO BOX 687
JENKINTOWN PA
19046-3706
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-0800
  • Fax: 215-685-0846
Mailing address:
  • Phone: 215-671-4280
  • Fax: 215-464-9034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DENNIS ENEANYA
Title or Position: PRESIDENT
Credential: MD
Phone: 215-671-4280