Basic Information
| Provider Information | |||||||||
| NPI: | 1649629056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | MARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 S 11TH ST | ||||||||
| Address2: | SUITE 8490 GIBBON | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 12/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | HS000240L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.