Healthcare Provider Details

I. General information

NPI: 1861596892
Provider Name (Legal Business Name): SAMUEL PHILLIP WYCHE JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 FLOURTOWN AVE SUITE 1 B
WYNDMOOR PA
19038-7976
US

IV. Provider business mailing address

8200 FLOURTOWN AVE SUITE 1 B
WYNDMOOR PA
19038-7976
US

V. Phone/Fax

Practice location:
  • Phone: 215-836-7014
  • Fax:
Mailing address:
  • Phone: 215-836-7014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS-005924-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: