Healthcare Provider Details

I. General information

NPI: 1396787917
Provider Name (Legal Business Name): RICHARD LEWIS IRVING III MHS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE 3/208N
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-3133
  • Fax: 215-707-3945
Mailing address:
  • Phone: 215-707-8561
  • Fax: 215-707-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-00728
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA052325
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: