Healthcare Provider Details

I. General information

NPI: 1487635587
Provider Name (Legal Business Name): ROBERT ALAN PROMISLOFF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CITY LINE AVE WB 113
WYNNEWOOD PA
19096-3902
US

IV. Provider business mailing address

1001 CITY LINE AVE WB 113
WYNNEWOOD PA
19096-3902
US

V. Phone/Fax

Practice location:
  • Phone: 610-896-0280
  • Fax: 610-896-0286
Mailing address:
  • Phone: 610-896-0280
  • Fax: 610-896-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberOS003149L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: