Provider Demographics
NPI:1790914331
Name:MARYMORBARIATRICSLLC
Entity Type:Organization
Organization Name:MARYMORBARIATRICSLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARYMOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-715-2316
Mailing Address - Street 1:24 OLD COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-1202
Mailing Address - Country:US
Mailing Address - Phone:610-715-2316
Mailing Address - Fax:610-353-0878
Practice Address - Street 1:100 W SPROUL RD
Practice Address - Street 2:SUITE 224
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-2033
Practice Address - Country:US
Practice Address - Phone:610-715-2316
Practice Address - Fax:610-353-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-03
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026704E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C34832Medicare UPIN