Basic Information
Provider Information | |||||||||
NPI: | 1588767180 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LERMAN | ||||||||
FirstName: | ROY | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 S HENDERSON RD | ||||||||
Address2: | SUITE 308C | ||||||||
City: | KING OF PRUSSIA | ||||||||
State: | PA | ||||||||
PostalCode: | 19406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6103373111 | ||||||||
FaxNumber: | 6103373506 | ||||||||
Practice Location | |||||||||
Address1: | 700 S HENDERSON RD | ||||||||
Address2: | SUITE 308C | ||||||||
City: | KING OF PRUSSIA | ||||||||
State: | PA | ||||||||
PostalCode: | 19406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6103373111 | ||||||||
FaxNumber: | 6103373506 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2006 | ||||||||
LastUpdateDate: | 04/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD044357L | PA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 000734369 | 01 | PA | BCBS PERSONAL CHOICE | OTHER | 1030074 | 01 | PA | KEYSTONE MERCY | OTHER | 3074576 | 01 | PA | CIGNA | OTHER | 0638218000 | 01 | PA | KEYSTONE HPE | OTHER | 0016708170001 | 05 | PA |   | MEDICAID | 455144 | 01 | PA | AETNA | OTHER |