Basic Information
| Provider Information | |||||||||
| NPI: | 1427045871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500-2345 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172635562 | ||||||||
| FaxNumber: | 7172631566 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191483542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159529323 | ||||||||
| FaxNumber: | 2159521246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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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 | 207L00000X | MD069006L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0017879540004 | 05 | PA | MEDICAID |