Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | OA002318 | PA |
NPI | 1003387572 |
---|---|
Provider Name | Carissa Susan Mcilwain |
First Address | Bryn Mawr, PA 19010-1024 |
Second Address | Bala Cynwyd, PA 19004-3215 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2018 |
Last Update Date | 10/12/2018 |