Provider Demographics
NPI:1881649721
Name:PENN EXECUTIVE DIAGNOSTIC CENTER, INC.
Entity Type:Organization
Organization Name:PENN EXECUTIVE DIAGNOSTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:SPITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-569-9500
Mailing Address - Street 1:1801 MARKET ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1628
Mailing Address - Country:US
Mailing Address - Phone:215-569-9500
Mailing Address - Fax:215-569-4839
Practice Address - Street 1:1801 MARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1628
Practice Address - Country:US
Practice Address - Phone:215-569-9500
Practice Address - Fax:215-569-4839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty