Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD436173 | PA |
N | 207QS0010X | Family Doctor - Sports Medicine | MD436173 | PA |
NPI | 1184822504 |
---|---|
Provider Name | Susan Fidler |
First Address | Jenkintown, PA 19046-2852 |
Second Address | Jenkintown, PA 19046-2852 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2007 |
Last Update Date | 15/02/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
102502102 | (05) | PA |