Healthcare Provider Details

I. General information

NPI: 1063320398
Provider Name (Legal Business Name): MARY JANE ANN BASILICA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N BROAD ST
PHILADELPHIA PA
19122-6117
US

IV. Provider business mailing address

1600 N BROAD ST
PHILADELPHIA PA
19121-3489
US

V. Phone/Fax

Practice location:
  • Phone: 215-204-7000
  • Fax:
Mailing address:
  • Phone: 555-555-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: