Healthcare Provider Details

I. General information

NPI: 1144246232
Provider Name (Legal Business Name): GPHA PODIATRY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 FRANKFORD AVE
PHILADELPHIA PA
19124-3602
US

IV. Provider business mailing address

432 N 6TH ST
PHILADELPHIA PA
19123-4004
US

V. Phone/Fax

Practice location:
  • Phone: 215-744-1302
  • Fax:
Mailing address:
  • Phone: 215-925-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MIXZA SANTA
Title or Position: MANAGED CARE COORDINATOR
Credential:
Phone: 215-925-2400