Provider Demographics
NPI:1508893926
Name:ENNIS, PETER D (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:ENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LAWRENCE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3301
Mailing Address - Country:US
Mailing Address - Phone:610-492-5900
Mailing Address - Fax:610-492-5903
Practice Address - Street 1:30 LAWRENCE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3301
Practice Address - Country:US
Practice Address - Phone:610-492-5900
Practice Address - Fax:610-492-5903
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059272L207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2512918OtherAETNA HMO
PA7910189OtherAETNA TRADITIONAL
PA0651758000OtherIBC
PA779455OtherBLUE SHIELD
PA7910189OtherAETNA TRADITIONAL
PA0651758000OtherIBC