Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | MT217618 | PA |
Y | 111NI0900X | Internist | MT217618 | PA |
NPI | 1003475955 |
---|---|
Provider Name | Dr. Brenton Shaw Halsey III |
First Address | Philadelphia, PA 19140-5103 |
Second Address | Philadelphia, PA 19140-5103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2019 |
Last Update Date | 12/06/2019 |