Healthcare Provider Details

I. General information

NPI: 1215997085
Provider Name (Legal Business Name): HENRY FUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2434
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-6900
  • Fax: 215-214-3779
Mailing address:
  • Phone: 215-728-6900
  • Fax: 215-214-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number036113770
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD450472
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: