Healthcare Provider Details

I. General information

NPI: 1265466510
Provider Name (Legal Business Name): GREGORY MOKRYNSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 S BROAD ST SUITE 205
PHILADELPHIA PA
19148-3542
US

IV. Provider business mailing address

615 CHESTNUT ST 14TH FLOOR
PHILADELPHIA PA
19106-4404
US

V. Phone/Fax

Practice location:
  • Phone: 215-551-8660
  • Fax: 215-551-9247
Mailing address:
  • Phone: 215-955-1175
  • Fax: 215-955-2420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD039490E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: