Basic Information
| Provider Information | |||||||||
| NPI: | 1285682047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANILEWITZ | ||||||||
| FirstName: | MERVYN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W ELM ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194284108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105676964 | ||||||||
| FaxNumber: | 6105676955 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S 54TH ST | ||||||||
| Address2: | 4 FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157489833 | ||||||||
| FaxNumber: | 2157489864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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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 | 207R00000X | MD061765L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | MD061765L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001778169 | 05 | PA | MEDICAID |