Provider Demographics
NPI:1952640187
Name:PENN INTEGRATIVE MEDICAL AND DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:PENN INTEGRATIVE MEDICAL AND DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-821-2305
Mailing Address - Street 1:7130 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3957
Mailing Address - Country:US
Mailing Address - Phone:215-821-2305
Mailing Address - Fax:215-220-2600
Practice Address - Street 1:7130 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3957
Practice Address - Country:US
Practice Address - Phone:215-821-2305
Practice Address - Fax:215-220-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027913640001Medicaid