=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477355782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE EDWARD HABARTH-MORALES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2025
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 SPRUCE ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-4238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-789-7366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 E LANCASTER AVE APT 403
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19087-5133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-564-0692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | MT234517
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------