=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548310899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AILEEN GONG DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 926 ARCH ST 1 ST FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-232-0564
-----------------------------------------------------
Fax | 610-270-0508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 348 WINDING WAY
-----------------------------------------------------
City | KING OF PRUSSIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19406-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-272-8839
-----------------------------------------------------
Fax | 610-270-0508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | SC004596L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------