=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316359482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEA ANNE MOUKARZEL M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2014
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 OLD YORK RD STE 3
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19141-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-456-7180
-----------------------------------------------------
Fax | 215-456-7052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E OLNEY AVE STE 400
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19120-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-456-1825
-----------------------------------------------------
Fax | 215-456-5926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 4410
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VX0201X
-----------------------------------------------------
Taxonomy Name | Gynecologic Oncology Physician
-----------------------------------------------------
License Number | MD477353
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------