Healthcare Provider Details

I. General information

NPI: 1447272406
Provider Name (Legal Business Name): ERIC AZVOLINSKY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SPRUCE ST BSMT WEST
PHILADELPHIA PA
19106-4022
US

IV. Provider business mailing address

2500 MARYLAND RD STE 504
WILLOW GROVE PA
19090-1226
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-3358
  • Fax:
Mailing address:
  • Phone: 215-481-4836
  • Fax: 215-481-5788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA051111
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: