Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | OS012617 | PA |
NPI | 1275670655 |
---|---|
Provider Name | Dr. Michael E Srulevich |
First Address | Havertown, PA 19083-5410 |
Second Address | Crum Lynne, PA 19022-1022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 01/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1019420800003 | (05) | PA |
I30831 | (02) | PA |