Healthcare Provider Details

I. General information

NPI: 1013601541
Provider Name (Legal Business Name): FORNANCE PHYSICIAN SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 W GERMANTOWN PIKE STE 105
PLYMOUTH MEETING PA
19462-1032
US

IV. Provider business mailing address

PO BOX 789967
PHILADELPHIA PA
19178-9967
US

V. Phone/Fax

Practice location:
  • Phone: 610-941-6881
  • Fax: 610-941-6635
Mailing address:
  • Phone: 484-622-7395
  • Fax: 414-622-7399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY JONES
Title or Position: PROVIDER ENROLLMENT MANAGER
Credential:
Phone: 215-456-8129