Basic Information
| Provider Information | |||||||||
| NPI: | 1417040528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULTE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 CHESTNUT ST | ||||||||
| Address2: | SUITE 1321 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159554730 | ||||||||
| FaxNumber: | 2155039188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 CHESTNUT ST | ||||||||
| Address2: | SUITE 1321 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159554730 | ||||||||
| FaxNumber: | 2155039188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD442950 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0000X | MD442950 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | 213816 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | MD442950 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 102613907 | 05 | PA | MEDICAID | 0193054 | 05 | NJ | MEDICAID |