Basic Information
| Provider Information | |||||||||
| NPI: | 1558467209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SJOHOLM | ||||||||
| FirstName: | LARS OLA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073133 | ||||||||
| FaxNumber: | 2157073945 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | 4TH FL PARKINSON PAVILION | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073133 | ||||||||
| FaxNumber: | 2157073945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | MD435706 | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 208600000X | MD435706 | PA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0002181 | 01 | PA | AETNA | OTHER | 2684555000 | 01 | BLUE SHIELD KEYSTONE AMERIHEALTH | OTHER | 60021848 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 0095087 | 05 | NJ | MEDICAID | 2623781 | 01 | NJ | UNITED HEALTHCARE | OTHER | 91001907400 | 01 | NJ | AMERICHOICE | OTHER | 2078341 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 3K6094 | 01 | NJ | HEALTNET | OTHER | P00292748 | 01 | NJ | RR MEDICARE | OTHER | 1134057 | 01 | NJ | AETNA | OTHER |