1891069977 NPI number — FOX CHASE CANCER CENTER MEDICAL GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891069977 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:
PULM 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:
1891069977
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:
215-214-4044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 COTTMAN AVE
Provider Second Line Business Practice Location Address:
FOX CHASE CANCER CENTER
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:
215-214-4044
Provider Enumeration Date:
03/07/2012

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: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1026888280018 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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