Basic Information
| Provider Information | |||||||||
| NPI: | 1174973580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKOLOSKY | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARROLL | ||||||||
| OtherFirstName: | CHELSEA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CHELSEA CARROLL D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5501 OLD YORK RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154563834 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD | ||||||||
| Address2: | ALBERT EINSTEIN MEDICAL CENTER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154563834 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OT017127 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | OT017127 | 01 | PA | PA TRAINING LICENSE | OTHER |