=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235663881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLAUS MEPHIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2017
-----------------------------------------------------
Last Update Date | 03/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7600 CENTRAL AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19111-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-728-2276
-----------------------------------------------------
Fax | 215-214-4119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2450 W HUNTING PARK AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19129-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-926-9022
-----------------------------------------------------
Fax | 215-226-8286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 66948
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | TMD005234
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | MD472732
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------