Basic Information
| Provider Information | |||||||||
| NPI: | 1730848417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADNOR FAMILY PRACTICE, PLLC, DBA IM HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IM HEALTH URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 372 W LANCASTER AVE FL 1 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190873924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106888807 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 372 W LANCASTER AVE FL 1 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190873924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106888807 | ||||||||
| FaxNumber: | 6106882970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2021 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISK | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6106888807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADNOR FAMILY PRACTICE, PLLC, DBA IM HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.