Healthcare Provider Details

I. General information

NPI: 1104605542
Provider Name (Legal Business Name): HAILEY SAMANTHA MARCUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PENN BLVD STE 108
PHILADELPHIA PA
19144-1402
US

IV. Provider business mailing address

631 WISES MILL RD
PHILADELPHIA PA
19128-3118
US

V. Phone/Fax

Practice location:
  • Phone: 215-842-0406
  • Fax:
Mailing address:
  • Phone: 267-421-4589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOA006616
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: