Provider Demographics
NPI:1821039132
Name:PROFESSIONAL PROVIDERS INC
Entity Type:Organization
Organization Name:PROFESSIONAL PROVIDERS INC
Other - Org Name:WHITELAND MEDICAL ASSOCIATES FOR PROGRESSIVE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBOUTILLIER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:610-738-8016
Mailing Address - Street 1:1244 W CHESTER PIKE
Mailing Address - Street 2:SUITE 409
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-5657
Mailing Address - Country:US
Mailing Address - Phone:610-738-8016
Mailing Address - Fax:610-918-6316
Practice Address - Street 1:119 E UWCHLAN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1206
Practice Address - Country:US
Practice Address - Phone:610-363-1995
Practice Address - Fax:610-363-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071051Medicare ID - Type UnspecifiedGROUP ID