Healthcare Provider Details

I. General information

NPI: 1538083548
Provider Name (Legal Business Name): FOGGY BOTTOM PHYSICIAN GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 M ST NW STE 910
WASHINGTON DC
20037-1434
US

IV. Provider business mailing address

367 S GULPH RD
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-3422
  • Fax:
Mailing address:
  • Phone: 610-382-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY RODRIGUEZ
Title or Position: COO
Credential: COO
Phone: 610-382-3397