Provider Demographics
NPI:1194723585
Name:GOLLOMP, STEPHEN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:GOLLOMP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:SUITE 161
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-642-5371
Mailing Address - Fax:610-642-5658
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:SUITE 161
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:610-642-5371
Practice Address - Fax:610-642-5658
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024887E2084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0808737Medicaid
PAB37644Medicare UPIN
PA0808737Medicaid