MEDICARE: MADELEINE E.M. GATES

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	1041C0700X	Clinical Social Worker	CW022045	PA

General Provider Information

NPI Number	:	1134858186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELEINE E.M. GATES

Provider Business Mailing Address
First Line	:	4021 PARKSIDE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-1087
Country	:	US
Telephone Number	:	267-225-8381
Fax Number	:

Provider Business Practice Location Address
First Line	:	4021 PARKSIDE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-1087
Country	:	US
Telephone Number	:	267-225-8381
Fax Number	:

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

Provider Enumeration Date	:	06/06/2022
Last Update Date	:	06/06/2022

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