Healthcare Provider Details

I. General information

NPI: 1851362859
Provider Name (Legal Business Name): MICHAEL A MANFREDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

10 W PROSPECT AVE
MOORESTOWN NJ
08057-3522
US

V. Phone/Fax

Practice location:
  • Phone: 617-833-5824
  • Fax:
Mailing address:
  • Phone: 617-833-5824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD478164
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: