Provider Demographics
NPI:1245629146
Name:EASTERN PENNSYLVANIA PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:EASTERN PENNSYLVANIA PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-829-8550
Mailing Address - Street 1:3113 LAWTON RD
Mailing Address - Street 2:STE 250
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3531
Mailing Address - Country:US
Mailing Address - Phone:888-829-8550
Mailing Address - Fax:855-418-9149
Practice Address - Street 1:160 W GERMANTOWN PIKE
Practice Address - Street 2:STE D
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19401-1386
Practice Address - Country:US
Practice Address - Phone:888-829-8550
Practice Address - Fax:855-418-9149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAXCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003411L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHC059OtherMEDICARE PTAN