MEDICARE: BOHDAN M MINCZAK MD

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	207P00000X	Emergency Medicine Physician	MD064462L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396738456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOHDAN M MINCZAK MD

Provider Business Mailing Address
First Line	:	1601 CHERRY ST
Second Line	:	SUITE 11511
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1320
Country	:	US
Telephone Number	:	215-255-7822
Fax Number	:	215-255-7825

Provider Business Practice Location Address
First Line	:	245 N 15TH STREET
Second Line	:	NCB ROOM 2108
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102
Country	:	US
Telephone Number	:	215-762-2361
Fax Number	:	215-762-1307

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	05/13/2016

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