Provider Demographics
NPI:1538501192
Name:VANSANT MEDICINE, INC
Entity Type:Organization
Organization Name:VANSANT MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANSANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-551-0200
Mailing Address - Street 1:901 E PASSYUNK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-2924
Mailing Address - Country:US
Mailing Address - Phone:215-551-0200
Mailing Address - Fax:215-551-0209
Practice Address - Street 1:901 E PASSYUNK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-2924
Practice Address - Country:US
Practice Address - Phone:215-551-0200
Practice Address - Fax:215-551-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006091L111N00000X
PAOS010207L207QA0505X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA18130700001Medicaid
PA18130700001Medicaid
PAH18014Medicare UPIN