=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457883936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAYFAIR PAIN THERAPY CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2017
-----------------------------------------------------
Last Update Date | 04/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6921 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19135-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-708-8887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6921 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19135-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-708-8887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. GERALD E DWORKIN
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 610-996-2018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | OS004891L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------