Provider Demographics
NPI:1225650930
Name:THE MODERN COUNTRY DOCTOR, LLC
Entity Type:Organization
Organization Name:THE MODERN COUNTRY DOCTOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FAITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-890-8522
Mailing Address - Street 1:23 INDUSTRIAL BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1601
Mailing Address - Country:US
Mailing Address - Phone:610-890-8522
Mailing Address - Fax:484-568-4748
Practice Address - Street 1:23 INDUSTRIAL BLVD STE D
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1601
Practice Address - Country:US
Practice Address - Phone:610-890-8522
Practice Address - Fax:484-568-4748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty