=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528418373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ELIZABETH PEASE D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2016
-----------------------------------------------------
Last Update Date | 09/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 S BRYN MAWR AVE
-----------------------------------------------------
City | BRYN MAWR
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19010-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-337-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 FOX CREEK RD
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19312-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-356-3483
-----------------------------------------------------
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 | OT017208
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | OS020007
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------