Provider Demographics
NPI:1093826588
Name:HELLER, STEPHEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:HELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-9900
Mailing Address - Fax:215-707-3831
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-9900
Practice Address - Fax:215-707-3831
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434004207RG0100X
MA79199207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021573140001Medicaid
PA1021573140001Medicaid
MA3199240Medicaid
MA100012381Medicare PIN
PA125173JEWMedicare PIN
MAJ21094Medicare PIN
MAJ21094OtherBLUE CROSS/BLUE SHIELD #