Healthcare Provider Details

I. General information

NPI: 1013973981
Provider Name (Legal Business Name): EVAN GELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 A ST
PHILADELPHIA PA
19134-1043
US

IV. Provider business mailing address

3115 W COULTER ST
PHILADELPHIA PA
19129-1001
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-5230
  • Fax:
Mailing address:
  • Phone: 215-844-5243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD043322E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: