Healthcare Provider Details

I. General information

NPI: 1467514794
Provider Name (Legal Business Name): GENERAL PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 CECIL B MOORE AVE
PHILA PA
19122
US

IV. Provider business mailing address

703 CECIL B MOORE AVE
PHILA PA
19122
US

V. Phone/Fax

Practice location:
  • Phone: 215-763-9564
  • Fax: 215-763-1165
Mailing address:
  • Phone: 215-763-9564
  • Fax: 215-763-1165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier041759GGJ
Identifier TypeOTHER
Identifier State
Identifier IssuerPHYSICIAN MEDICARE

VIII. Authorized Official

Name: MYRON RODOS
Title or Position: PHYSICIAN
Credential: DO
Phone: 215-763-9564