Provider Demographics
NPI:1184229270
Name:OLD TOWN HEALTH LLC
Entity Type:Organization
Organization Name:OLD TOWN HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:DEEPA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANDON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:610-969-5215
Mailing Address - Street 1:4700 E THOMAS RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-7702
Mailing Address - Country:US
Mailing Address - Phone:610-969-5215
Mailing Address - Fax:
Practice Address - Street 1:4700 E THOMAS RD STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7702
Practice Address - Country:US
Practice Address - Phone:610-969-5215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty