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General NPI Number Information
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NPI Number | 1134273311
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Entity Type | Organization
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Legal Business Name | STREET ROAD SURGERY CENTER, LLC
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4979 OLD STREET RD
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City | TREVOSE
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State | PA
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Zip | 19053-6222
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Country | US
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Telephone | 215-355-7027
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Fax | 215-355-7028
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Provider Business Mailing Address
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Address Line | 4979 OLD STREET RD
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City | TREVOSE
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State | PA
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Zip | 19053-6222
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Country | US
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Telephone | 215-355-7027
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Fax | 215-355-7028
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. EVELYN WITKIN
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Credential | M.D.
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Telephone | 215-355-7027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 2053
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License Number State | PA
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