Individual
ELIZA ERVIN FULTON THORNTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1055 WESTLAKES DR STE 3152, BERWYN, PA 19312-2410
(215) 346-6050
(215) 220-3562
Mailing address
500 KIRTS BLVD STE 100, TROY, MI 48084-4135
(248) 434-6169
(855) 618-6655
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
MD436674
PA
207QA0505X
Adult Medicine Physician
Primary
MD436674
PA
390200000X
Student in an Organized Health Care Education/Training Program
MT188666
PA
Other
Enumeration date
10/08/2008
Last updated
11/23/2020
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