=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427003904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILADELPHIA WOMEN'S CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 11/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 APPLETREE ST 7TH FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19106-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-574-3590
-----------------------------------------------------
Fax | 856-356-4038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 CHAPEL AVE E
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08034-1454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-356-4000
-----------------------------------------------------
Fax | 856-356-4038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | ANGELA LAZARUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-356-4001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 109639
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 00178701
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------