Healthcare Provider Details

I. General information

NPI: 1205562923
Provider Name (Legal Business Name): ABDUL MOKUM JR. BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 MARKET ST
PHILADELPHIA PA
19104-3133
US

IV. Provider business mailing address

1216 ARCH ST FL 6
PHILADELPHIA PA
19107-2835
US

V. Phone/Fax

Practice location:
  • Phone: 215-243-2800
  • Fax: 215-382-1691
Mailing address:
  • Phone: 215-981-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: