Provider Demographics
NPI:1578683017
Name:BAZELON, EILEEN AMY (MD)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:AMY
Last Name:BAZELON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CITY AVE
Mailing Address - Street 2:D-120
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2908
Mailing Address - Country:US
Mailing Address - Phone:215-477-3330
Mailing Address - Fax:215-477-3362
Practice Address - Street 1:3900 CITY AVE
Practice Address - Street 2:D-120
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19131-2908
Practice Address - Country:US
Practice Address - Phone:215-477-3330
Practice Address - Fax:215-477-3362
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD013268E2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA019708Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION N