Basic Information
| Provider Information | |||||||||
| NPI: | 1104921576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DREXEL UNIVERSITY | ||||||||
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| OtherOrganizationName: | DREXEL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 219 N BROAD ST | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191071519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157621545 | ||||||||
| FaxNumber: | 2155635514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | JANIEC | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PAYER CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 2152557766 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.