Provider Demographics
NPI:1154781300
Name:EZELL, KASEIM
Entity type:Individual
Prefix:
First Name:KASEIM
Middle Name:
Last Name:EZELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 MONTELLA CIR
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1217
Mailing Address - Country:US
Mailing Address - Phone:215-696-2300
Mailing Address - Fax:
Practice Address - Street 1:3908 MONTELLA CIR
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-1217
Practice Address - Country:US
Practice Address - Phone:215-696-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies