Healthcare Provider Details

I. General information

NPI: 1902976202
Provider Name (Legal Business Name): 7622 MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7622 OGONTZ AVE
PHILADELPHIA PA
19150-1817
US

IV. Provider business mailing address

7622 OGONTZ AVE
PHILADELPHIA PA
19150-1817
US

V. Phone/Fax

Practice location:
  • Phone: 215-224-8980
  • Fax: 215-224-9342
Mailing address:
  • Phone: 215-224-8980
  • Fax: 215-224-9342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE BYNUM
Title or Position: MEDICARE DEPARTMENT
Credential:
Phone: 215-224-8980