Provider Demographics
NPI:1376575100
Name:PROVIDENCE MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL ASSOCIATES, INC
Other - Org Name:KESSLER KESSLER GRECO & ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REX
Authorized Official - Middle Name:K
Authorized Official - Last Name:KESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-876-2300
Mailing Address - Street 1:PO BOX 1897
Mailing Address - Street 2:
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-7897
Mailing Address - Country:US
Mailing Address - Phone:610-876-2300
Mailing Address - Fax:610-876-3004
Practice Address - Street 1:2901 DUTTON MILL RD
Practice Address - Street 2:STE 110
Practice Address - City:ASTON
Practice Address - State:PA
Practice Address - Zip Code:19014-2849
Practice Address - Country:US
Practice Address - Phone:610-876-2300
Practice Address - Fax:610-876-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020904E207R00000X
PAMD035193E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA510238Medicare ID - Type Unspecified