MEDICARE: PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE

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	103TC0700X	Clinical Psychologist	PS016978	PA

General Provider Information

NPI Number	:	1316230220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE

Provider Business Mailing Address
First Line	:	4190 CITY AVE
Second Line	:	SUITE 777
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-1633
Country	:	US
Telephone Number	:	215-871-6910
Fax Number	:	215-871-6905

Provider Business Practice Location Address
First Line	:	4190 CITY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-1633
Country	:	US
Telephone Number	:	215-871-6910
Fax Number	:	251-871-6905

Authorized Official
Title or Position	:	SVP OF ACADEMIC AFFAIRS AND DEAN
Name	:	KENNETH VEIT
Credential	:	DO
Telephone Number	:	215-871-6770

Provider Enumeration Date	:	05/25/2011
Last Update Date	:	01/10/2012

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