Provider Demographics
NPI:1518371756
Name:WALSH, STEPHANIE TANNER (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:TANNER
Last Name:WALSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LEIGH
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER BLVD OFC
Mailing Address - Street 2:3 EAST RESIDENCY OFFICE
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3902
Mailing Address - Country:US
Mailing Address - Phone:610-447-6682
Mailing Address - Fax:610-447-6677
Practice Address - Street 1:30 MEDICAL CENTER BLVD
Practice Address - Street 2:POB1, SUITE 205, CROZER PEDIATRICS
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-3955
Practice Address - Country:US
Practice Address - Phone:610-619-7410
Practice Address - Fax:610-876-8483
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10143800208000000X
DEC1-0012210208000000X
PAMD462124208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics