MEDICARE: ROMAN DYKYJ JR. M.D.

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	207R00000X	Internal Medicine Physician	MD027187E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0054192000	OTHER	PA	INDEPENDENT BLUE CROSS
2	A00995	OTHER	PA	AMERIHEALTH ADMINISTRATOR
3	2061288	OTHER	PA	AETNA
4	0054192001	OTHER	PA	KEYSTONE HPE

General Provider Information

NPI Number	:	1891882973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROMAN DYKYJ JR. M.D.

Provider Business Mailing Address
First Line	:	8151 REVERE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3002
Country	:	US
Telephone Number	:	215-624-3000
Fax Number	:	215-624-6855

Provider Business Practice Location Address
First Line	:	8151 REVERE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3002
Country	:	US
Telephone Number	:	215-624-3000
Fax Number	:	215-624-6855

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

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	12/18/2007

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