Individual
KISHA VANTERPOOL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
3401 N BROAD ST, PHILADELPHIA, PA 19140-5103
(215) 707-9403
(215) 225-1698
Mailing address
5410 MARYLAND WAY, SUITE 300, BRENTWOOD, TN 37027-5064
(615) 377-5652
(888) 241-1404
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
MD429577
PA
208M00000X
Hospitalist Physician
036139805
IL
208M00000X
Hospitalist Physician
Primary
MD429577
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1017395200001
—
PA
05
—
1017395200002
—
PA
05
—
1017395200003
—
PA
01
—
2094018
HIGHMARK BLUE SHIELD
PA
01
—
2855050000
BCBS OF PA
PA
Enumeration date
08/20/2006
Last updated
03/29/2021
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