=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447722863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED WOUND CARE PENNSYLVANIA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2018
-----------------------------------------------------
Last Update Date | 02/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 W GIRARD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-705-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 492C CEDAR LN STE 514
-----------------------------------------------------
City | TEANECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07666-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-705-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DIANE LUSA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-705-6010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------