Healthcare Provider Details

I. General information

NPI: 1376570630
Provider Name (Legal Business Name): MEDICAL PSYCHIATRIC ASSOCIATES OF DELAWARE VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 ROOSEVELT BLVD
PHILADELPHIA PA
19124-2343
US

IV. Provider business mailing address

4641 ROOSEVELT BLVD
PHILADELPHIA PA
19124-2343
US

V. Phone/Fax

Practice location:
  • Phone: 215-831-7932
  • Fax:
Mailing address:
  • Phone: 215-831-7932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ELLEN GITTLEMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 215-831-7932