Healthcare Provider Details

I. General information

NPI: 1215927736
Provider Name (Legal Business Name): JEROLD MIKSZEWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST 2 RAVDIN
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

3400 SPRUCE ST 2 RAVDIN
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3606
  • Fax: 215-349-5579
Mailing address:
  • Phone: 215-662-3606
  • Fax: 215-349-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101030137
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD021941E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: