| NPI | 1972701308 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER PROVASNIK Supervisor Of Provider Enrollment 800-355-0808 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Enumeration Date | 2007-07-06 |
| Last Update Date | 2008-04-20 |