Provider Demographics
NPI:1396787917
Name:IRVING, RICHARD LEWIS III (MHS, PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEWIS
Last Name:IRVING
Suffix:III
Gender:M
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:3/208N
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-8561
Mailing Address - Fax:215-707-3677
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3133
Practice Address - Fax:215-707-3945
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00728363AS0400X
PAMA052325363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0476PAMedicaid
PA097773FP6Medicare ID - Type UnspecifiedHGSA
SC0476PAMedicaid
NC2767884Medicare PIN