Provider Demographics
NPI:1992744197
Name:PHELAN, GERALD R (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:R
Last Name:PHELAN
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 1:6005 CRICKET RD
Mailing Address - Street 2:
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-1202
Mailing Address - Country:US
Mailing Address - Phone:215-248-5600
Mailing Address - Fax:215-242-0160
Practice Address - Street 1:39 E CHESTNUT HILL AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2728
Practice Address - Country:US
Practice Address - Phone:215-248-5600
Practice Address - Fax:215-242-0160
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018700E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007826030001Medicaid
PA179525Medicare PIN
PA0007826030001Medicaid