Healthcare Provider Details

I. General information

NPI: 1366491938
Provider Name (Legal Business Name): BANGOR PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 N 11TH ST
BANGOR PA
18013-1603
US

IV. Provider business mailing address

325 BLUE VALLEY DR
BANGOR PA
18013-1526
US

V. Phone/Fax

Practice location:
  • Phone: 610-588-6621
  • Fax: 610-588-6307
Mailing address:
  • Phone: 610-588-6621
  • Fax: 610-588-6307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC004468L
License Number StatePA

VIII. Authorized Official

Name: DR. CHERALYN PERKINS
Title or Position: PRESIDENT
Credential: DPM
Phone: 610-588-6621