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General NPI Number Information
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NPI Number | 1861921389
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Entity Type | Organization
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Legal Business Name | VINE STREET MEDICAL AND ASSOCIATES
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Dates
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Enumeration Date | 06/08/2017
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 6323 VINE ST
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City | PHILADELPHIA
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State | PA
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Zip | 19139-1032
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Country | US
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Telephone | 267-292-5638
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Fax | 267-292-5648
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Provider Business Mailing Address
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Address Line | 6323 VINE ST
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City | PHILADELPHIA
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State | PA
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Zip | 19139-1032
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Country | US
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Telephone | 267-292-5638
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Fax | 267-292-5648
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Authorized Official
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Title or Position | ADMIN
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Name | SHARI JOHNSON
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Credential |
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Telephone | 267-292-5638
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | MD032595E
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License Number State | PA
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