Provider Demographics
NPI:1932454923
Name:STOLL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:STOLL MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:STOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-615-3020
Mailing Address - Street 1:1528 WALNUT ST
Mailing Address - Street 2:SUITE 950
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1528 WALNUT ST STE 950
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3628
Practice Address - Country:US
Practice Address - Phone:215-531-4564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027200860002Medicaid