Healthcare Provider Details

I. General information

NPI: 1750194569
Provider Name (Legal Business Name): PENNMED CARE PA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 E HUNTING PARK AVE STE 110
PHILADELPHIA PA
19124-4813
US

IV. Provider business mailing address

PO BOX 9369
PHILADELPHIA PA
19139-9369
US

V. Phone/Fax

Practice location:
  • Phone: 215-709-3800
  • Fax: 215-476-1427
Mailing address:
  • Phone: 215-709-3800
  • Fax: 215-476-1427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN MANZELLA
Title or Position: ADMINISTRATOR
Credential: DO
Phone: 215-709-3800