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General NPI Number Information
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NPI Number | 1225650930
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Entity Type | Organization
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Legal Business Name | THE MODERN COUNTRY DOCTOR, LLC
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Dates
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Enumeration Date | 05/15/2020
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Last Update Date | 05/15/2020
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Provider Practice Location Address
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Address Line | 23 INDUSTRIAL BLVD STE D
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City | PAOLI
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State | PA
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Zip | 19301-1601
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Country | US
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Telephone | 610-890-8522
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Fax | 484-568-4748
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Provider Business Mailing Address
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Address Line | 23 INDUSTRIAL BLVD STE D
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City | PAOLI
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State | PA
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Zip | 19301-1601
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Country | US
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Telephone | 610-890-8522
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Fax | 484-568-4748
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Authorized Official
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Title or Position | OWNER
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Name | DR. DENNIS FAITH
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Credential | MD
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Telephone | 610-890-8522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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