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General NPI Number Information
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NPI Number | 1932505385
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Entity Type | Organization
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Legal Business Name | OLIVE BRANCH MEDICAL CENTER
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Dates
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Enumeration Date | 11/12/2014
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Last Update Date | 09/28/2015
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Provider Practice Location Address
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Address Line | 2 BALA PLZ STE 50
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City | BALA CYNWYD
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State | PA
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Zip | 19004-1501
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Country | US
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Telephone | 215-200-3913
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Fax |
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Provider Business Mailing Address
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Address Line | 5427 WAYNE AVE APT G22
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City | PHILADELPHIA
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State | PA
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Zip | 19144-3455
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Country | US
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Telephone | 215-200-3913
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LORETTA F BROWN
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Credential | D.O.
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Telephone | 215-200-3913
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS004959L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OS004959L
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License Number State | PA
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