Basic Information
Provider Information | |||||||||
NPI: | 1891759478 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANPELT | ||||||||
FirstName: | MERRITT | ||||||||
MiddleName: | JOAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 615 CHESTNUT ST | ||||||||
Address2: | 14TH FLOOR | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191064404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159559457 | ||||||||
FaxNumber: | 2159552420 | ||||||||
Practice Location | |||||||||
Address1: | 111 S 11TH ST | ||||||||
Address2: | THOMAS JEFFERSON UNIVERSITY HOSPITAL | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159556844 | ||||||||
FaxNumber: | 2159552526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2006 | ||||||||
LastUpdateDate: | 10/31/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD423619 | PA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1622698 | 01 | PA | HIGHMARK BS | OTHER | 2299670000 | 01 | PA | INDEPENDENCE BC | OTHER | 0127892 | 05 | NJ |   | MEDICAID | 1010400400001 | 05 | PA |   | MEDICAID |