Healthcare Provider Details

I. General information

NPI: 1154687804
Provider Name (Legal Business Name): ANDREW EVERETT WELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

833 CHESTNUT ST STE 210
PHILADELPHIA PA
19107-4405
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-7555
  • Fax:
Mailing address:
  • Phone: 215-955-9823
  • Fax: 215-503-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD452882
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: