MEDICARE: PHYLLIS L. EHRLICH

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	171W00000X	Contractor	OC000030L	PA

General Provider Information

NPI Number	:	1073630026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS L. EHRLICH

Provider Business Mailing Address
First Line	:	6434 HENRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1507
Country	:	US
Telephone Number	:	215-483-1107
Fax Number	:	215-509-6737

Provider Business Practice Location Address
First Line	:	12265 TOWNSEND RD
Second Line	:	SUITE 400
City	:	PHILA
State	:	PA
Zip	:	19154-1201
Country	:	US
Telephone Number	:	215-856-1329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/08/2007

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