MEDICARE: MEDICALLY ASSISTED RECOVERY SERVICES INC

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	207RA0401X	Addiction Medicine (Internal Medicine) Physician	OS004029L	PA

General Provider Information

NPI Number	:	1770960882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICALLY ASSISTED RECOVERY SERVICES INC

Provider Business Mailing Address
First Line	:	10802 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3302
Country	:	US
Telephone Number	:	215-969-6277
Fax Number	:	215-856-7313

Provider Business Practice Location Address
First Line	:	10802 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3302
Country	:	US
Telephone Number	:	215-969-6277
Fax Number	:	215-856-7313

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. JAN N WIDERMAN
Credential	:	D.O.
Telephone Number	:	215-969-6277

Provider Enumeration Date	:	04/28/2015
Last Update Date	:	07/06/2015

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