MEDICARE: 1223 SOUTH 15TH STREET CORPORATION

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	332BC3200X	Customized Equipment (DME)	6000003764	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

General Provider Information

NPI Number	:	1396799722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1223 SOUTH 15TH STREET CORPORATION

Provider Business Mailing Address
First Line	:	2745 W PASSYUNK AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4012
Country	:	US
Telephone Number	:	215-334-3816
Fax Number	:	215-334-1998

Provider Business Practice Location Address
First Line	:	2745 W PASSYUNK AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4012
Country	:	US
Telephone Number	:	215-334-3816
Fax Number	:	215-334-1998

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CARLO A. COCCO
Credential	:	BCO
Telephone Number	:	215-334-3816

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/22/2020

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