Healthcare Provider Details

I. General information

NPI: 1003376054
Provider Name (Legal Business Name): MICHAEL JOSEPH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 09/23/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3824 NORTHERN PIKE STE 820
PHILADELPHIA PA
19131-1626
US

IV. Provider business mailing address

4190 CITY AVE
PHILADELPHIA PA
19131-1626
US

V. Phone/Fax

Practice location:
  • Phone: 215-871-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS023872
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: