=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356363253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTOR ELIAS GHANTOUS M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 05/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 735 FITZWATERTOWN RD
-----------------------------------------------------
City | WILLOW GROVE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19090-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-657-2012
-----------------------------------------------------
Fax | 215-657-2018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 735 FITZWATERTOWN RD
-----------------------------------------------------
City | WILLOW GROVE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19090-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-657-2012
-----------------------------------------------------
Fax | 215-657-2018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | MD068220L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------