Provider Demographics
NPI:1790703593
Name:PENNSBURY MEDICAL PRACTICE, P.C.
Entity Type:Organization
Organization Name:PENNSBURY MEDICAL PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-736-2508
Mailing Address - Street 1:201 WOOLSTON DRIVE
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:MORRISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19067
Mailing Address - Country:US
Mailing Address - Phone:215-736-2508
Mailing Address - Fax:215-736-0744
Practice Address - Street 1:201 WOOLSTON DRIVE
Practice Address - Street 2:SUITE 1E
Practice Address - City:MORRISVILLE
Practice Address - State:PA
Practice Address - Zip Code:19067
Practice Address - Country:US
Practice Address - Phone:215-736-2508
Practice Address - Fax:215-736-0744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003138L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017998840001Medicaid
PA0017998840001Medicaid
PA104046Medicare PIN