MEDICARE: MARIA L FUDALA P.A.

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	363AS0400X	Surgical Physician Assistant	MA051378	PA
2	363AM0700X	Medical Physician Assistant	MA051378	PA

General Provider Information

NPI Number	:	1891812863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA L FUDALA P.A.

Provider Business Mailing Address
First Line	:	545 W GERMANTOWN PIKE
Second Line	:	SUITE 100
City	:	PLYMOUTH MEETING
State	:	PA
Zip	:	19462-1349
Country	:	US
Telephone Number	:	484-351-8268
Fax Number	:	484-351-8275

Provider Business Practice Location Address
First Line	:	545 W GERMANTOWN PIKE
Second Line	:	SUITE 100
City	:	PLYMOUTH MEETING
State	:	PA
Zip	:	19462-1349
Country	:	US
Telephone Number	:	484-351-8268
Fax Number	:	484-351-8275

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	03/19/2019

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