Healthcare Provider Details

I. General information

NPI: 1841842887
Provider Name (Legal Business Name): AILISH CAMERON COBLENTZ MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF RADIOLOGY
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD DIVISION OF RADIOLOGY
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMT218767
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: