Provider Demographics
NPI:1548288236
Name:WALLINGFORD MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:WALLINGFORD MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:REX
Authorized Official - Middle Name:K
Authorized Official - Last Name:KESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-876-2300
Mailing Address - Street 1:PO BOX 1897
Mailing Address - Street 2:
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-7897
Mailing Address - Country:US
Mailing Address - Phone:610-876-2300
Mailing Address - Fax:610-876-3004
Practice Address - Street 1:2901 DUTTON MILL RD
Practice Address - Street 2:STE 110
Practice Address - City:ASTON
Practice Address - State:PA
Practice Address - Zip Code:19014-2849
Practice Address - Country:US
Practice Address - Phone:610-876-2300
Practice Address - Fax:610-876-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035193E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2060989001OtherKEYSTONE HEALTH PLAN EAST
PA19949OtherAETNA
PA1612690Medicaid
PA19949OtherAETNA
C33007Medicare UPIN