MEDICARE: ROOSEVELT FAMILY MEDICAL CENTER, INC.

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0058484001	OTHER	PA	10 DIGIT HMO ID

General Provider Information

NPI Number	:	1114035326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOSEVELT FAMILY MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	4517 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19140-1215
Country	:	US
Telephone Number	:	215-324-1900
Fax Number	:	215-324-4239

Provider Business Practice Location Address
First Line	:	4517 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19140-1215
Country	:	US
Telephone Number	:	215-324-1900
Fax Number	:	215-324-4239

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MAURICE SINGER
Credential	:	D.O.
Telephone Number	:	215-676-3336

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	08/22/2020

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