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General NPI Number Information
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NPI Number | 1437694809
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Entity Type | Organization
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Legal Business Name | VAGABONDING THROUGH THE ETHER
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Dates
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Enumeration Date | 12/21/2016
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Last Update Date | 01/13/2017
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Provider Practice Location Address
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Address Line | 1300 HORIZON DR STE 101
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City | CHALFONT
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State | PA
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Zip | 18914-3970
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Country | US
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Telephone | 267-225-4759
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 HORIZON DR STE 101
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City | CHALFONT
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State | PA
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Zip | 18914-3970
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Country | US
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Telephone | 267-225-4759
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. SAMUEL GRODOFSKY
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Credential | MD
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Telephone | 267-225-4759
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | MD451221
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | MD451221
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License Number State | PA
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