Provider Demographics
NPI:1215057914
Name:IMBODY, ALFRED W (CRNA)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:W
Last Name:IMBODY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 S BROAD ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3542
Mailing Address - Country:US
Mailing Address - Phone:215-952-9323
Mailing Address - Fax:
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-952-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR11843500367500000X
PARN540700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA15100Medicare PIN