Provider Demographics
NPI:1356669246
Name:STANLEY J. TRAVIS, JR, D.O., P.C.
Entity Type:Organization
Organization Name:STANLEY J. TRAVIS, JR, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:215-672-6877
Mailing Address - Street 1:501 BUCKMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-1402
Mailing Address - Country:US
Mailing Address - Phone:215-672-6877
Mailing Address - Fax:215-672-6812
Practice Address - Street 1:501 BUCKMAN DRIVE
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-1402
Practice Address - Country:US
Practice Address - Phone:215-672-6877
Practice Address - Fax:215-672-6812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002173L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00606544-01Medicaid
TR041691Medicare PIN
PA00606544-01Medicaid