Healthcare Provider Details

I. General information

NPI: 1164684601
Provider Name (Legal Business Name): MT AIRY/ GERMANTOWN MEDICAL AND REHAB ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 N BROAD ST
PHILADELPHIA PA
19141-2307
US

IV. Provider business mailing address

5751 N BROAD ST
PHILADELPHIA PA
19141-2307
US

V. Phone/Fax

Practice location:
  • Phone: 215-843-0672
  • Fax: 215-843-0674
Mailing address:
  • Phone: 215-843-0672
  • Fax: 215-843-0674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD061558L
License Number StatePA

VIII. Authorized Official

Name: MR. GEORGE EDWARD FISHER
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 215-843-0672