MEDICARE: TRIANGLE MEDICAL, 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	OS006195-L	PA

General Provider Information

NPI Number	:	1275707671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIANGLE MEDICAL, INC.

Provider Business Mailing Address
First Line	:	1202 LOCUST ST
Second Line	:	SUITE 201
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5605
Country	:	US
Telephone Number	:	215-545-0170
Fax Number	:	215-545-8677

Provider Business Practice Location Address
First Line	:	1202 LOCUST ST
Second Line	:	SUITE 201
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5605
Country	:	US
Telephone Number	:	215-545-0170
Fax Number	:	215-545-8677

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. MARK T WATKINS
Credential	:	D.O.
Telephone Number	:	215-545-0170

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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