MEDICARE: JAN N WIDERMAN P.C.

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	261QP2300X	Primary Care Clinic/Center	OS004029L	PA

General Provider Information

NPI Number	:	1962657346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAN N WIDERMAN P.C.

Provider Business Mailing Address
First Line	:	10800 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3302
Country	:	US
Telephone Number	:	215-934-6777
Fax Number	:	215-934-6787

Provider Business Practice Location Address
First Line	:	10800 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3302
Country	:	US
Telephone Number	:	215-934-6777
Fax Number	:	215-934-6787

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JAN N. WIDERMAN
Credential	:	DO
Telephone Number	:	215-934-6777

Provider Enumeration Date	:	11/26/2008
Last Update Date	:	11/26/2008

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