Basic Information
Provider Information | |||||||||
NPI: | 1356342372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEMELS | ||||||||
FirstName: | LISA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 420 BAINBRIDGE ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191471568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2156293837 | ||||||||
FaxNumber: | 2156295531 | ||||||||
Practice Location | |||||||||
Address1: | 734 E LANCASTER AVE | ||||||||
Address2: |   | ||||||||
City: | VILLANOVA | ||||||||
State: | PA | ||||||||
PostalCode: | 190851325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109641700 | ||||||||
FaxNumber: | 6106882000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2005 | ||||||||
LastUpdateDate: | 04/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT010142L | PA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 2083306000 | 01 | PA | BC/BS HMO | OTHER | 1394051 | 01 | PA | BC/BS PPO | OTHER | 000810593243 | 01 | PA | PHCS | OTHER | 7311639 | 01 | PA | AETNA | OTHER |