=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770137218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH CARE AT NORTHEAST PHILADELPHIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2019
-----------------------------------------------------
Last Update Date | 08/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3353 COTTMAN AVENUE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19149-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-332-4410
-----------------------------------------------------
Fax | 215-332-6255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3353 COTTMAN AVENUE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19149-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-332-4410
-----------------------------------------------------
Fax | 215-332-6255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN
-----------------------------------------------------
Name | DANIEL YANFENG LIN
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 814-381-5881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------