MEDICARE: SVETLANA DE JOHN PA

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	363AM0700X	Medical Physician Assistant	OA000517L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	044560JT9	OTHER	PA	MEDICARE IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1124103023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SVETLANA DE JOHN PA

Provider Business Mailing Address
First Line	:	2500 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4615
Country	:	US
Telephone Number	:	215-605-8096
Fax Number	:	215-424-5365

Provider Business Practice Location Address
First Line	:	2135 E CHELTEN AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19138-2534
Country	:	US
Telephone Number	:	215-424-5365
Fax Number	:	215-424-5370

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	08/01/2016

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Directions to “ SVETLANA DE JOHN PA” Practice Location

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