Provider Demographics
NPI:1538127907
Name:WHITENACK, STEPHAN HARRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:HARRIS
Last Name:WHITENACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-8735
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-8735
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:KLEIN 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-6178
Practice Address - Fax:215-456-6204
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD016782E208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006557540001Medicaid
PA0006557540001Medicaid
B40015Medicare UPIN