Provider Demographics
NPI:1790856078
Name:WEST GROVE CLINIC COMPANY LLC
Entity type:Organization
Organization Name:WEST GROVE CLINIC COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VF & CFO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-628-8181
Mailing Address - Street 1:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 W BALTIMORE PIKE STE 304
Practice Address - Street 2:
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-9448
Practice Address - Country:US
Practice Address - Phone:610-869-1278
Practice Address - Fax:610-869-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 2085R0202X
PAMD034333L207RC0000X
PAMD427096207RG0100X
PA207X00000X, 208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018284230003Medicaid
PA1018284230003Medicaid