=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679030605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE WIRTSHAFTER DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2019
-----------------------------------------------------
Last Update Date | 08/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E. MORELAND AVE. SUITE 100
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19118-3562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-437-3176
-----------------------------------------------------
Fax | 267-437-3176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 E. MORELAND AVE. SUITE 100
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19118-3562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-385-5538
-----------------------------------------------------
Fax | 267-437-3176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | OS021115
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------