Healthcare Provider Details

I. General information

NPI: 1154734622
Provider Name (Legal Business Name): COLLEGEVILLE MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 W MAIN ST
TRAPPE PA
19426-1948
US

IV. Provider business mailing address

PO BOX 299
DELAWARE WATER GAP PA
18327-0299
US

V. Phone/Fax

Practice location:
  • Phone: 601-489-8645
  • Fax: 610-489-6329
Mailing address:
  • Phone: 610-489-8645
  • Fax: 610-489-6329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. KEM YENAL
Title or Position: OWNER
Credential: MD
Phone: 610-489-8645