Provider Demographics
NPI:1174596530
Name:INTERNAL MEDICINE SPECIALIST LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:PURPURA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:215-322-5002
Mailing Address - Street 1:80 SECOND STREET PIKE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3800
Mailing Address - Country:US
Mailing Address - Phone:215-322-5002
Mailing Address - Fax:215-322-5008
Practice Address - Street 1:80 SECOND STREET PIKE
Practice Address - Street 2:SUITE 2
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3800
Practice Address - Country:US
Practice Address - Phone:215-322-5002
Practice Address - Fax:215-322-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009043L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
034025TNROtherMEDICARE PROVIDER NUMBER
086875Medicare ID - Type UnspecifiedGROUP NUMBER
G81415Medicare UPIN