Provider Demographics
NPI:1437694809
Name:VAGABONDING THROUGH THE ETHER
Entity Type:Organization
Organization Name:VAGABONDING THROUGH THE ETHER
Other - Org Name:VAGABONDING THROUGH THE ETHER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRODOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-225-4759
Mailing Address - Street 1:1300 HORIZON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHALFONT
Mailing Address - State:PA
Mailing Address - Zip Code:18914-3970
Mailing Address - Country:US
Mailing Address - Phone:267-225-4759
Mailing Address - Fax:
Practice Address - Street 1:1300 HORIZON DR STE 101
Practice Address - Street 2:
Practice Address - City:CHALFONT
Practice Address - State:PA
Practice Address - Zip Code:18914-3970
Practice Address - Country:US
Practice Address - Phone:267-225-4759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD451221207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty