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General NPI Number Information
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NPI Number | 1134677644
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Entity Type | Organization
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Legal Business Name | PROMD
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Dates
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Enumeration Date | 09/13/2016
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Last Update Date | 09/13/2016
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Provider Practice Location Address
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Address Line | 608 BERKLEY ST
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City | CAMDEN
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State | NJ
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Zip | 08103-1414
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Country | US
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Telephone | 832-567-1808
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Fax |
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Provider Business Mailing Address
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Address Line | 5058 CITY LINE AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19131-1441
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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 | PHYSICIAN OWNER
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Name | DR. TELISHA ORTIZ
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Credential | M.D.
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Telephone | 832-567-1808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | MD456019
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License Number State | PA
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