Provider Demographics
NPI:1093760845
Name:SAG, JEROME E (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:E
Last Name:SAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5393
Mailing Address - Country:US
Mailing Address - Phone:215-361-5010
Mailing Address - Fax:267-517-9029
Practice Address - Street 1:1101 S BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5393
Practice Address - Country:US
Practice Address - Phone:215-361-5010
Practice Address - Fax:267-517-9029
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017164E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC28885Medicare UPIN