MEDICARE: MR. PETER MANGA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN289972	PA

General Provider Information

NPI Number	:	1073888384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER MANGA

Provider Business Mailing Address
First Line	:	2146 S BROAD ST
Second Line	:	2FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3905
Country	:	US
Telephone Number	:	267-519-0672
Fax Number	:

Provider Business Practice Location Address
First Line	:	2146 S BROAD ST
Second Line	:	2FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3905
Country	:	US
Telephone Number	:	267-519-0672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2012
Last Update Date	:	03/20/2012

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