Provider Demographics
NPI:1285871780
Name:GERSON, LEROY T (MD)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:T
Last Name:GERSON
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 1:611 FOXFIELDS RD
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2056
Mailing Address - Country:US
Mailing Address - Phone:610-520-0770
Mailing Address - Fax:
Practice Address - Street 1:611 FOXFIELDS RD
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2056
Practice Address - Country:US
Practice Address - Phone:610-520-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 007963E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC27146Medicare UPIN