Healthcare Provider Details

I. General information

NPI: 1013367309
Provider Name (Legal Business Name): MARIYA VENGRENYUK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 CENTRAL AVE FL 2
PHILADELPHIA PA
19111-2442
US

IV. Provider business mailing address

245 N 15TH ST FL 6
PHILADELPHIA PA
19102-1101
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-2276
  • Fax: 215-214-4119
Mailing address:
  • Phone: 215-762-7000
  • Fax: 215-762-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number84258
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD468755
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number302324
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT212010
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: