Basic Information
| Provider Information | |||||||||
| NPI: | 1124260054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCANN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 CHESTNUT ST | ||||||||
| Address2: | 14TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159552141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 S 11TH ST | ||||||||
| Address2: | SUITE 3390 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556226 | ||||||||
| FaxNumber: | 2159231562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD436196 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1022806590001 | 05 | PA | MEDICAID | 0190811 | 05 | NJ | MEDICAID |