Provider Demographics
NPI:1770960882
Name:MEDICALLY ASSISTED RECOVERY SERVICES INC
Entity type:Organization
Organization Name:MEDICALLY ASSISTED RECOVERY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:WIDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-969-6277
Mailing Address - Street 1:10802 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3302
Mailing Address - Country:US
Mailing Address - Phone:215-969-6277
Mailing Address - Fax:215-856-7313
Practice Address - Street 1:10802 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3302
Practice Address - Country:US
Practice Address - Phone:215-969-6277
Practice Address - Fax:215-856-7313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004029L207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty