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General NPI Number Information
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NPI Number | 1003459702
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Entity Type | Organization
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Legal Business Name | TOWER DREXEL ACADEMIC MEDICAL GROUP LLC
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Dates
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Enumeration Date | 10/25/2019
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Last Update Date | 10/21/2020
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Provider Practice Location Address
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Address Line | 4700 WISSAHICKON AVE STE C102
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City | PHILADELPHIA
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State | PA
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Zip | 19144-4248
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Country | US
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Telephone | 610-743-6049
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 13579
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City | READING
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State | PA
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Zip | 19612-3579
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP & CFO
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Name | GARY CONNER
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Credential |
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Telephone | 484-628-1324
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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