Provider Demographics
NPI:1225044688
Name:JOAN E. HURLOCK, MD, LLC
Entity Type:Organization
Organization Name:JOAN E. HURLOCK, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HURLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-482-4542
Mailing Address - Street 1:600 SEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2713
Mailing Address - Country:US
Mailing Address - Phone:215-482-7844
Mailing Address - Fax:
Practice Address - Street 1:5735 RIDGE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1745
Practice Address - Country:US
Practice Address - Phone:215-482-4542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012610E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102572Medicare PIN
B34436Medicare UPIN