=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306801667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER TIOSECO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2006
-----------------------------------------------------
Last Update Date | 02/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 W JIMMIE LEEDS RD CHOP CARE NETWORK @ ATLANTICARE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08240-9102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-404-3816
-----------------------------------------------------
Fax | 609-404-3818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E PENN SQ 9TH FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-425-9232
-----------------------------------------------------
Fax | 267-425-9299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | MA74232
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 25MA07423200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------