MEDICARE: EASY STRIDE PAIN & INJURY CENTER, PC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	SC-001795-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073543559	OTHER	PA	NPI INDIVIDUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1049959	OTHER	PA	KEYSTONE MERCY - EASY STR
4	31700	OTHER	PA	KEYSTONE MERCY INDIVIDUAL
5	0050052704	OTHER	PA	AMERICHOICE OF PA INDIVID

General Provider Information

NPI Number	:	1366591596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASY STRIDE PAIN & INJURY CENTER, PC

Provider Business Mailing Address
First Line	:	4014 LANCASTER AVE # A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-1712
Country	:	US
Telephone Number	:	215-222-2225
Fax Number	:	215-222-3070

Provider Business Practice Location Address
First Line	:	4014 LANCASTER AVE # A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-1712
Country	:	US
Telephone Number	:	215-222-2225
Fax Number	:	215-222-3070

Authorized Official
Title or Position	:	PODIATRIST
Name	:	DR. J GREGORY BANCROFT
Credential	:	D.P.M.
Telephone Number	:	215-222-2225

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	08/22/2020

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