MEDICARE: IYI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1104084391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IYI

Provider Business Mailing Address
First Line	:	6425 TULIP ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19135-3324
Country	:	US
Telephone Number	:	215-971-7389
Fax Number	:

Provider Business Practice Location Address
First Line	:	6425 TULIP ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19135-3324
Country	:	US
Telephone Number	:	215-971-7389
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	DR. WILLY KASONGO
Credential	:	M.D., R.V.S.
Telephone Number	:	215-971-7389

Provider Enumeration Date	:	05/25/2008
Last Update Date	:	05/25/2008

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Directions to “IYI ” Practice Location

Language	Start Address	Practice Location

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