=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639474976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY HEALTH MID-ATLANTIC MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2011
-----------------------------------------------------
Last Update Date | 09/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 FLORAL VALE BLVD
-----------------------------------------------------
City | YARDLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-750-7150
-----------------------------------------------------
Fax | 215-750-7153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 UNIVERSITY DRIVE SUITE 300
-----------------------------------------------------
City | NEWTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18940-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-343-2654
-----------------------------------------------------
Fax | 215-710-5181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, FINANCE AND CFO
-----------------------------------------------------
Name | KIMBERLY A CUMMINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-710-2508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS-008612-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------