Healthcare Provider Details

I. General information

NPI: 1053997064
Provider Name (Legal Business Name): TYLER ALEC SIMOWITZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4170 CITY AVE
PHILADELPHIA PA
19131-1610
US

IV. Provider business mailing address

401 ROUTE 73 N STE 320
MARLTON NJ
08053-3426
US

V. Phone/Fax

Practice location:
  • Phone: 215-871-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00646800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA063522
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: