=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851734255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA LYNN HEIRY M.B., B.CH., BAO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2013
-----------------------------------------------------
Last Update Date | 09/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 WALNUT ST FL 4
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-2724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 MEADOWFIELD LN
-----------------------------------------------------
City | JEFFERSON HILLS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15025-3022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-655-3462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD467888
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------