=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831104496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BECKY A SOUDER DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 INDUSTRIAL BLVD SUITE 103
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19301-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-786-3200
-----------------------------------------------------
Fax | 610-786-3208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 INDUSTRIAL BLVD SUITE 103
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19301-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-786-3200
-----------------------------------------------------
Fax | 610-786-3208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS010701L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------