MEDICARE: DOUGLASS BREATH OF LIFE

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	227800000X	Certified Respiratory Therapist	YM006253L	PA

General Provider Information

NPI Number	:	1831479047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLASS BREATH OF LIFE

Provider Business Mailing Address
First Line	:	3901 CONSHOHOCKEN AVENUE
Second Line	:	#8308
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131
Country	:	US
Telephone Number	:	215-877-1114
Fax Number	:	215-877-1114

Provider Business Practice Location Address
First Line	:	3901 CONSHOHOCKEN AVE
Second Line	:	#8308
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-5430
Country	:	US
Telephone Number	:	215-877-1114
Fax Number	:	215-877-1114

Authorized Official
Title or Position	:	CERTIFIED RESPIRATORY THERAPIST
Name	:	MR. LYDELL DOUGLASS
Credential	:
Telephone Number	:	215-877-1114

Provider Enumeration Date	:	08/18/2011
Last Update Date	:	08/18/2011

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