=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114908050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MENACHEM MELLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 05/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S 54TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-748-9822
-----------------------------------------------------
Fax | 215-748-9717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 W ELM ST
-----------------------------------------------------
City | CONSHOHOCKEN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19428-2007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-567-6964
-----------------------------------------------------
Fax | 610-567-6170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | MD042497
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------