MEDICARE: PROFESSIONAL HEALTHCARE DYNAMICS

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	207VG0400X	Gynecology Physician	OS003098L	PA

General Provider Information

NPI Number	:	1679953798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL HEALTHCARE DYNAMICS

Provider Business Mailing Address
First Line	:	1313 WOLF ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2911
Country	:	US
Telephone Number	:	215-465-3000
Fax Number	:	215-465-1085

Provider Business Practice Location Address
First Line	:	1313 WOLF ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2911
Country	:	US
Telephone Number	:	215-465-3000
Fax Number	:	215-465-1085

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	RICHARD J DITTRICH
Credential	:	D.O.
Telephone Number	:	215-465-3000

Provider Enumeration Date	:	06/03/2015
Last Update Date	:	06/03/2015

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