Basic Information
| Provider Information | |||||||||
| NPI: | 1750407144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADNOR FAMILY PRACTICE PROFESSIONAL LIMITED LIABILITY COMPANY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IM HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 372 W LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190873924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106888807 | ||||||||
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| Practice Location | |||||||||
| Address1: | 372 W LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190873924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106888807 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | ROCKLAN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6106888807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADNOR FAMILY PRACTICE PROFESSIONAL LIMITED LIABILITY COMPANY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.