Provider Demographics
NPI:1669414827
Name:SHORT, WILLIAM R (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:SHORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3910 N POWELTON AVE
Mailing Address - Street 2:2ND FLR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-9008
Mailing Address - Fax:
Practice Address - Street 1:3910 N POWELTON AVE
Practice Address - Street 2:2ND FLR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-9008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD069187L207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0010669Medicaid
PA100819152Medicaid
PAH95768Medicare UPIN
PA073957Medicare PIN