Healthcare Provider Details

I. General information

NPI: 1407873441
Provider Name (Legal Business Name): PATRICIA A TAKACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N 39TH ST MUTCH BUILDING, 5TH FLOOR
PHILADELPHIA PA
19104-2640
US

IV. Provider business mailing address

51 N 39TH ST MUTCH BUILDING, 5TH FLOOR
PHILADELPHIA PA
19104-2640
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2775
  • Fax: 215-615-5055
Mailing address:
  • Phone: 215-662-2775
  • Fax: 215-615-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD431875
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD431875
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD431875
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: