Basic Information
| Provider Information | |||||||||
| NPI: | 1932595485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESANTIS | ||||||||
| FirstName: | ELIZA | ||||||||
| MiddleName: | CAROLINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRADKIN | ||||||||
| OtherFirstName: | ELIZA | ||||||||
| OtherMiddleName: | CAROLINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 1210 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074428 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 1210 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159552074 | ||||||||
| FaxNumber: | 2158610408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2015 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD464274 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | MT208953 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | C7-00007186 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | 25MA10378300 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | C7-0005869 | 01 | DE | DE TRAINING LICENSE | OTHER |