Healthcare Provider Details

I. General information

NPI: 1417988189
Provider Name (Legal Business Name): MONA M. SHANGOLD, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WALNUT ST SUITE 1200
PHILADELPHIA PA
19102-2944
US

IV. Provider business mailing address

1601 WALNUT ST SUITE 1200
PHILADELPHIA PA
19102-2944
US

V. Phone/Fax

Practice location:
  • Phone: 215-851-0999
  • Fax: 215-851-0996
Mailing address:
  • Phone: 215-851-0999
  • Fax: 215-851-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD-043719-E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD-043719-E
License Number StatePA

VIII. Authorized Official

Name: DR. MONA MARLYNN SHANGOLD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 215-851-0999