Provider Demographics
NPI:1740414820
Name:BECKER, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BECKER
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 1:5501 OLD YORK ROAD, KORMAN BASEMENT
Mailing Address - Street 2:TABOR EMERGENCY PHYSICIANS
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19141
Mailing Address - Country:US
Mailing Address - Phone:215-456-6679
Mailing Address - Fax:215-456-8502
Practice Address - Street 1:5501 OLD YORK ROAD, KORMAN BASEMENT
Practice Address - Street 2:TABOR EMERGENCY PHYSICIANS
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19141
Practice Address - Country:US
Practice Address - Phone:215-456-6679
Practice Address - Fax:215-456-8502
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4367000207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232664784OtherTIN 232664784