Healthcare Provider Details

I. General information

NPI: 1043311764
Provider Name (Legal Business Name): WYNCOTE PHYSICAL MEDICINE & DIAGNOSTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WASHINGTON LN STE 13C
WYNCOTE PA
19095-1400
US

IV. Provider business mailing address

25 WASHINGTON LN STE 13C
WYNCOTE PA
19095-1400
US

V. Phone/Fax

Practice location:
  • Phone: 215-887-5030
  • Fax: 215-887-5525
Mailing address:
  • Phone: 215-887-5030
  • Fax: 215-887-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD039601L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. AMELIA L TABUENA
Title or Position: ATTENDING PHYSICIAN
Credential: MD
Phone: 215-887-5030