Healthcare Provider Details

I. General information

NPI: 1700698685
Provider Name (Legal Business Name): SHAWN JUDE MCILVAIN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 GLENSIDE AVE
WYNCOTE PA
19095
US

IV. Provider business mailing address

3234 PEBBLEWOOD LANE
DRESTER PA
19025
US

V. Phone/Fax

Practice location:
  • Phone: 215-392-2892
  • Fax:
Mailing address:
  • Phone: 215-934-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberLP-0010GI2
License Number StateDE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: