Provider Demographics
NPI:1366549594
Name:GREATER PHILADELPHIA ORAL SURGERY PC
Entity type:Organization
Organization Name:GREATER PHILADELPHIA ORAL SURGERY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-379-3382
Mailing Address - Street 1:401 TOWNSHIP LINE ROAD
Mailing Address - Street 2:SUITE 'C'
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027
Mailing Address - Country:US
Mailing Address - Phone:215-379-5520
Mailing Address - Fax:215-663-5934
Practice Address - Street 1:401 TOWNSHIP LINE ROAD
Practice Address - Street 2:SUITE 'C'
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027
Practice Address - Country:US
Practice Address - Phone:215-379-5520
Practice Address - Fax:215-663-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019726L204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA049309Medicare PIN
T75670Medicare UPIN