Provider Demographics
NPI:1851492474
Name:HAVERFORD FAMILY MEDICINE
Entity Type:Organization
Organization Name:HAVERFORD FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-649-6400
Mailing Address - Street 1:600 HAVERFORD RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041-1139
Mailing Address - Country:US
Mailing Address - Phone:610-649-6400
Mailing Address - Fax:
Practice Address - Street 1:600 HAVERFORD RD
Practice Address - Street 2:SUITE 205
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1139
Practice Address - Country:US
Practice Address - Phone:610-649-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040154L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1209404Medicaid
PA1209404Medicaid