MEDICARE: WYNCOTE PHYSICAL MEDICINE & DIAGNOSTIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	MD039601L	PA

General Provider Information

NPI Number	:	1043311764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYNCOTE PHYSICAL MEDICINE & DIAGNOSTIC PC

Provider Business Mailing Address
First Line	:	25 WASHINGTON LN
Second Line	:	STE 13C
City	:	WYNCOTE
State	:	PA
Zip	:	19095-1400
Country	:	US
Telephone Number	:	215-887-5030
Fax Number	:	215-887-5525

Provider Business Practice Location Address
First Line	:	25 WASHINGTON LN
Second Line	:	STE 13C
City	:	WYNCOTE
State	:	PA
Zip	:	19095-1400
Country	:	US
Telephone Number	:	215-887-5030
Fax Number	:	215-887-5525

Authorized Official
Title or Position	:	ATTENDING PHYSICIAN
Name	:	DR. AMELIA L TABUENA
Credential	:	MD
Telephone Number	:	215-887-5030

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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