Healthcare Provider Details

I. General information

NPI: 1124473426
Provider Name (Legal Business Name): BANGOR PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 NAZARETH PIKE
BETHLEHEM PA
18020-9080
US

IV. Provider business mailing address

325 BLUE VALLEY DR
BANGOR PA
18013-1526
US

V. Phone/Fax

Practice location:
  • Phone: 610-351-9244
  • Fax: 610-351-9247
Mailing address:
  • Phone: 610-588-6621
  • Fax: 610-588-6307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StatePA

VIII. Authorized Official

Name: CHERALYN PERKINS
Title or Position: OFFICE MANAGER
Credential:
Phone: 610-588-6621