Healthcare Provider Details

I. General information

NPI: 1760471411
Provider Name (Legal Business Name): CHARLES A JUNGREIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST 1 FL PARK AVE PAVILION
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

PO BOX 827783
PHILADELPHIA PA
19182-7783
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-7237
  • Fax: 215-707-9389
Mailing address:
  • Phone: 215-707-3911
  • Fax: 215-707-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD035952E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: