Healthcare Provider Details

I. General information

NPI: 1679873970
Provider Name (Legal Business Name): MAENPAA SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 SPRUCE ST SUITE308
PHILADELPHIA PA
19107-5752
US

IV. Provider business mailing address

486 KING AVE
COLLINGSWOOD NJ
08108-1430
US

V. Phone/Fax

Practice location:
  • Phone: 215-334-5346
  • Fax:
Mailing address:
  • Phone: 610-209-2912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD073775-L
License Number StatePA

VIII. Authorized Official

Name: DR. GARATH ALAN MAENPAA
Title or Position: OWNER
Credential: MD
Phone: 610-209-2912