Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MD435873 | PA |
N | 207Q00000X | Family Doctor | MT188739 | PA |
Y | 207QS0010X | Family Doctor - Sports Medicine | MD435873 | PA |
NPI | 1114049566 |
---|---|
Provider Name | Dr. Jeremy David Close |
First Address | Philadelphia, PA 19107-4405 |
Second Address | Philadelphia, PA 19107-4216 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2007 |
Last Update Date | 22/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
102521117 | (05) | PA |