Healthcare Provider Details

I. General information

NPI: 1194723585
Provider Name (Legal Business Name): STEPHEN MICHAEL GOLLOMP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 02/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE SUITE 161
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

100 E LANCASTER AVE SUITE 161
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 610-642-5371
  • Fax: 610-642-5658
Mailing address:
  • Phone: 610-642-5371
  • Fax: 610-642-5658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD024887E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD024887E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: