=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598761538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR ASSOCIATES OF SOUTHEASTER PENNSYLVANIA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 02/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E LANCASTER AVE STE 356EAST
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096-3450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-649-7625
-----------------------------------------------------
Fax | 610-649-3362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E LANCASTER AVE STE 356EAST
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096-3450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-649-7625
-----------------------------------------------------
Fax | 610-649-3362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MELISSA MABRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-649-7625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------