Provider Demographics
NPI:1144327255
Name:PERSUN, MICHELLE L (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:PERSUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1017
Mailing Address - Country:US
Mailing Address - Phone:610-667-3020
Mailing Address - Fax:610-667-1817
Practice Address - Street 1:1 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1017
Practice Address - Country:US
Practice Address - Phone:610-667-3020
Practice Address - Fax:610-667-1817
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD073596L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH93833Medicare UPIN
PA072320MLCMedicare ID - Type UnspecifiedMEDICARE PROVIDER