Provider Demographics
NPI:1932505385
Name:OLIVE BRANCH MEDICAL CENTER
Entity Type:Organization
Organization Name:OLIVE BRANCH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-200-3913
Mailing Address - Street 1:5427 WAYNE AVE APT G22
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3455
Mailing Address - Country:US
Mailing Address - Phone:215-200-3913
Mailing Address - Fax:
Practice Address - Street 1:2 BALA PLZ STE 50
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1501
Practice Address - Country:US
Practice Address - Phone:215-200-3913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004959L207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty