Healthcare Provider Details

I. General information

NPI: 1205322146
Provider Name (Legal Business Name): INDEPENDENT PHYSICIANS MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9908 ROOSEVELT BLVD
PHILADELPHIA PA
19115-1705
US

IV. Provider business mailing address

9908 ROOSEVELT BLVD
PHILADELPHIA PA
19115-1705
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-3300
  • Fax:
Mailing address:
  • Phone: 215-464-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA NARASAKI
Title or Position: MANAGER
Credential:
Phone: 215-464-3300