Basic Information
| Provider Information | |||||||||
| NPI: | 1457913873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 W. LANCASTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845651510 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 255 W. LANCASTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845651510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2019 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS022163 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | OT019373 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | OS022163 | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.