Healthcare Provider Details

I. General information

NPI: 1174290696
Provider Name (Legal Business Name): CHAD DONNELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S 8TH ST STE 2L
PHILADELPHIA PA
19106-4017
US

IV. Provider business mailing address

3045 GAUL ST
PHILADELPHIA PA
19134-4336
US

V. Phone/Fax

Practice location:
  • Phone: 267-322-7700
  • Fax:
Mailing address:
  • Phone: 267-241-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN609755
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: