Healthcare Provider Details

I. General information

NPI: 1104635515
Provider Name (Legal Business Name): DR ALA STANFORD CENTER FOR HEALTH EQUITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2025
Last Update Date: 01/01/2025
Certification Date: 01/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7979 STATE RD
PHILADELPHIA PA
19136-3407
US

IV. Provider business mailing address

2001 W LEHIGH AVE
PHILADELPHIA PA
19132-2652
US

V. Phone/Fax

Practice location:
  • Phone: 484-270-6200
  • Fax: 484-270-6200
Mailing address:
  • Phone: 484-270-6200
  • Fax: 484-270-6200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
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: MRS. CYNTHIA ANTOINETTE TAYLOR
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 484-270-6200