Basic Information
| Provider Information | |||||||||
| NPI: | 1902423890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SASSAMAN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2019 SPRING GARDEN ST APT 3F | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191305008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707651494 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10 SHURS LN | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191272123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159671632 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2020 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT221915 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 00000000000000000000 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.