Healthcare Provider Details

I. General information

NPI: 1114454170
Provider Name (Legal Business Name): STEPHANIE M RIVERA MORALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2017
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

100 E LANCASTER AVE STE B11
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 484-476-2658
  • Fax:
Mailing address:
  • Phone: 484-476-2658
  • Fax: 484-476-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMT229964
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: