Basic Information
| Provider Information | |||||||||
| NPI: | 1235107467 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIROSE | ||||||||
| FirstName: | HITOSHI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550340 | ||||||||
| FaxNumber: | 8563550330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 WALNUT ST RM 605 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155184418 | ||||||||
| FaxNumber: | 2158238222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD425075 | PA | N | Other Service Providers | Specialist | 208G00000X | 25MA10269800 | NJ | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 102333313 | 05 | PA | MEDICAID | 0202096 | 05 | NJ | MEDICAID |