Healthcare Provider Details

I. General information

NPI: 1003312810
Provider Name (Legal Business Name): SAMANTHA MEGAN WYCKOFF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA MEGAN LABIB MD

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 49TH ST
PHILADELPHIA PA
19139-2718
US

IV. Provider business mailing address

525 E 68TH ST
NEW YORK NY
10065-4870
US

V. Phone/Fax

Practice location:
  • Phone: 215-471-2600
  • Fax:
Mailing address:
  • Phone: 718-920-3185
  • Fax: 718-882-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number306481-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD480318
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: