Healthcare Provider Details

I. General information

NPI: 1427619790
Provider Name (Legal Business Name): MADELINE REGANIS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S. 11TH STREET 204 PAVILION
PHILADELPHIA PA
19107-4949
US

IV. Provider business mailing address

117 S. 11TH STREET 204 PAVILION
PHILADELPHIA PA
19107-4949
US

V. Phone/Fax

Practice location:
  • Phone: 215-503-3876
  • Fax:
Mailing address:
  • Phone: 215-503-3876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberOT019425
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: