1609140888 NPI number — FOX CHASE CANCER CENTER MEDICAL GROUP, INC

Table of content: (NPI 1609140888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609140888 NPI number — FOX CHASE CANCER CENTER MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOX CHASE CANCER CENTER MEDICAL GROUP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INFECT DIS ASSOC OF FCCC, MGI
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609140888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2450 W HUNTING PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19129-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-728-6900
Provider Business Mailing Address Fax Number:
215-214-1425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 COTTMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-728-6900
Provider Business Practice Location Address Fax Number:
215-214-1425
Provider Enumeration Date:
03/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WOODARD
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING/MANAGER
Authorized Official Telephone Number:
215-707-3911

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1026888280014 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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