Provider Demographics
NPI:1841796711
Name:DAVITA MEDICAL GROUP PHILADELPHIA, LLC
Entity Type:Organization
Organization Name:DAVITA MEDICAL GROUP PHILADELPHIA, LLC
Other - Org Name:TANDIGM CARE SERVICES (TCS)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TERRENCE
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-568-4678
Mailing Address - Street 1:300 FOUR FALLS CORPORATE CENTER
Mailing Address - Street 2:300 CONSHOHOCKEN STATE RD.
Mailing Address - City:WEST CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428
Mailing Address - Country:US
Mailing Address - Phone:215-496-4621
Mailing Address - Fax:474-621-5568
Practice Address - Street 1:300 FOUR FALLS CORPORATE CENTER
Practice Address - Street 2:300 CONSHOHOCKEN STATE RD.
Practice Address - City:WEST CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428
Practice Address - Country:US
Practice Address - Phone:215-496-4621
Practice Address - Fax:215-568-4746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-01
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty