MEDICARE: ELWYN

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1255573093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELWYN

Provider Business Mailing Address
First Line	:	111 ELWYN RD
Second Line	:
City	:	ELWYN
State	:	PA
Zip	:	19063-4622
Country	:	US
Telephone Number	:	610-891-2000
Fax Number	:	610-891-2106

Provider Business Practice Location Address
First Line	:	4040 MARKET ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3003
Country	:	US
Telephone Number	:	215-895-5500
Fax Number	:

Authorized Official
Title or Position	:	PAYER CONTRACT SPECIALIST
Name	:	DONNA K BUSCH
Credential	:
Telephone Number	:	445-206-3028

Provider Enumeration Date	:	03/25/2009
Last Update Date	:	02/19/2022

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