MEDICARE: GEORGE FORD III

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1235406943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE FORD III

Provider Business Mailing Address
First Line	:	2633 N SARTAIN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1411
Country	:	US
Telephone Number	:	267-528-7569
Fax Number	:

Provider Business Practice Location Address
First Line	:	2633 N SARTAIN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1411
Country	:	US
Telephone Number	:	267-528-7569
Fax Number	:

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

Provider Enumeration Date	:	11/23/2011
Last Update Date	:	11/23/2011

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Directions to “ GEORGE FORD III ” Practice Location

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