Healthcare Provider Details

I. General information

NPI: 1265485379
Provider Name (Legal Business Name): JAKE ALDEN KUSHNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 CIVIC CENTER BLVD CHOP ENDOCRINE, ARC 802C
PHILADELPHIA PA
19104-4318
US

IV. Provider business mailing address

3615 CIVIC CENTER BLVD CHOP ENDOCRINE, ARC 802C
PHILADELPHIA PA
19104-4318
US

V. Phone/Fax

Practice location:
  • Phone: 267-426-5717
  • Fax: 215-590-1605
Mailing address:
  • Phone: 267-426-5717
  • Fax: 215-590-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD423023
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD423023
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: