Provider Demographics
NPI:1881621878
Name:THAL, IRA MERVYN (MD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:MERVYN
Last Name:THAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-0376
Mailing Address - Country:US
Mailing Address - Phone:484-653-1416
Mailing Address - Fax:484-653-1414
Practice Address - Street 1:1361 E BOOT RD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-5934
Practice Address - Country:US
Practice Address - Phone:484-653-1416
Practice Address - Fax:484-653-1414
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD044987L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0560080000OtherKEYSTONE
1413362OtherPERSONAL CHOICE
110241724OtherRAILROAD MEDICARE
810561286OtherCIGNA
TH1413362OtherBLUE SHIELD
4339125OtherAETNA PPO