Basic Information
| Provider Information | |||||||||
| NPI: | 1508185919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAXMAN | ||||||||
| FirstName: | ALLA | ||||||||
| MiddleName: | ULITSKY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ULITSKY | ||||||||
| OtherFirstName: | ALLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8500-4081 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191784081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158561010 | ||||||||
| FaxNumber: | 2158561141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1648 HUNTINGDON PIKE | ||||||||
| Address2: | |||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159382100 | ||||||||
| FaxNumber: | 2159383908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2010 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS015954 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102735900 0008 | 05 | PA | MEDICAID |