=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053822437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON EBERTS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2017
-----------------------------------------------------
Last Update Date | 10/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E LANCASTER AVE STE 252
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-896-7360
-----------------------------------------------------
Fax | 610-896-5207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 350
-----------------------------------------------------
City | SELLERSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18960-0350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-723-2333
-----------------------------------------------------
Fax | 215-257-1800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MA059283
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------