Basic Information
| Provider Information | |||||||||
| NPI: | 1053516096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | GRACE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 513029 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191753029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557093112 | ||||||||
| FaxNumber: | 3027092413 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | RADIATION ONCOLOGY DEPT | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845264841 | ||||||||
| FaxNumber: | 4845264671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MD433763 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 25MA09450900 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0212491 | 05 | NJ | MEDICAID | P00764685 | 01 | PA | RAILROAD MEDICARE | OTHER | 102190918 | 05 | PA | MEDICAID |