Provider Demographics
NPI:1053487496
Name:HASBROUCK, EDITH D (MD)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:D
Last Name:HASBROUCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 TABOR ROAD SUITE 141
Mailing Address - Street 2:MOSS-CADD
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150
Mailing Address - Country:US
Mailing Address - Phone:215-456-9142
Mailing Address - Fax:215-456-9052
Practice Address - Street 1:1200 W TABOR RD
Practice Address - Street 2:SUITE 141
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3019
Practice Address - Country:US
Practice Address - Phone:215-456-9142
Practice Address - Fax:215-456-9052
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031068E207RG0300X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA190342Medicare ID - Type Unspecified
PAF67520Medicare UPIN