Healthcare Provider Details

I. General information

NPI: 1083069348
Provider Name (Legal Business Name): MIRANDA GORDON-ZIGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 KEY HWY
BALTIMORE MD
21230-5546
US

IV. Provider business mailing address

3737 MARKET ST 9TH FLOOR
PHILADELPHIA PA
19104-5545
US

V. Phone/Fax

Practice location:
  • Phone: 443-730-5697
  • Fax:
Mailing address:
  • Phone: 215-294-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberD0089451
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: