Basic Information
| Provider Information | |||||||||
| NPI: | 1750505939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JETER | ||||||||
| FirstName: | TAMIKA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | TAMIKA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194645008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103277000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194645008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103277000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD 431199 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1019057560001 | 01 | PA | PROMISE | OTHER | 30043160 | 01 | PA | KEYSTONE MERCY | OTHER | 2842342000 | 01 | PA | KEYSTONE | OTHER | 1962660 | 01 | PA | HIGHMARK BS | OTHER | 1962660 | 01 | PA | BS | OTHER | 101905759 | 05 | PA | MEDICAID |