Provider Demographics
NPI:1750449468
Name:RISING SUN FAMILY PRACTICE CENTER, INC.
Entity Type:Organization
Organization Name:RISING SUN FAMILY PRACTICE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:POULSHOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-742-9700
Mailing Address - Street 1:7131 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADEPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3924
Mailing Address - Country:US
Mailing Address - Phone:215-742-9700
Mailing Address - Fax:215-742-0828
Practice Address - Street 1:7131 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADEPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3924
Practice Address - Country:US
Practice Address - Phone:215-742-9700
Practice Address - Fax:215-742-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010589360003Medicaid
PA0010589360003Medicaid