Provider Demographics
NPI:1902154404
Name:PENNSYLVANIA INJURY CENTER
Entity Type:Organization
Organization Name:PENNSYLVANIA INJURY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPRINCE
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:215-672-2436
Mailing Address - Street 1:PO BOX 45856
Mailing Address - Street 2:6735 HARBISON AVENUE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-5856
Mailing Address - Country:US
Mailing Address - Phone:215-672-2436
Mailing Address - Fax:215-672-2437
Practice Address - Street 1:6735 HARBISON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2305
Practice Address - Country:US
Practice Address - Phone:215-672-2436
Practice Address - Fax:215-672-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG61554Medicare UPIN