Healthcare Provider Details

I. General information

NPI: 1669405346
Provider Name (Legal Business Name): CHARLES M. INTENZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S. 11TH STREET SUITE 3390
PHILADELPHIA PA
19107-4824
US

IV. Provider business mailing address

111 S. 11TH STREET SUITE 3390
PHILADELPHIA PA
19107-4824
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-2900
  • Fax: 215-923-1562
Mailing address:
  • Phone: 215-955-2900
  • Fax: 215-923-1562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD025932E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMD025932E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: