Basic Information
| Provider Information | |||||||||
| NPI: | 1386752160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRONOVOST | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157074600 | ||||||||
| FaxNumber: | 2157079697 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157074600 | ||||||||
| FaxNumber: | 2157079697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 037779 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD049051L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 001377797 | 05 | CT | MEDICAID |