Healthcare Provider Details

I. General information

NPI: 1063905115
Provider Name (Legal Business Name): ANAND SHRIPAD BHAGWAT MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BOULEVARD 9NW, ROOM 55
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD DIVISION OF HEMATOLOGY/ONCOLOGY
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1220
  • Fax:
Mailing address:
  • Phone: 215-590-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT215185
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMT215185
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: