Healthcare Provider Details

I. General information

NPI: 1104352533
Provider Name (Legal Business Name): ERNEST JAMES NELSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

3601 MARKET ST UNIT 2903
PHILADELPHIA PA
19104-5943
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1728
  • Fax:
Mailing address:
  • Phone: 229-291-8471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License NumberMT213676
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: