Basic Information
| Provider Information | |||||||||
| NPI: | 1538116041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRILLEY | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 CAPITAL WAY STE 220 | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085342523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093030747 | ||||||||
| FaxNumber: | 6093030771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 25MB11267100 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 0S004378L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1025078 | 05 | PA | MEDICAID | AC1582572 | 01 | DEA | OTHER | 2353601 | 05 | NJ | MEDICAID | FC0906620 | 01 | NJ | DEA | OTHER |