MEDICARE: DR. RONALD WILLIAM CHANNELL

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	213E00000X	Podiatrist	SC002419-L	PA

General Provider Information

NPI Number	:	1659328672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD WILLIAM CHANNELL

Provider Business Mailing Address
First Line	:	2314 E YORK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2120
Country	:	US
Telephone Number	:	215-634-0525
Fax Number	:	215-634-8402

Provider Business Practice Location Address
First Line	:	2314 E YORK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2120
Country	:	US
Telephone Number	:	215-634-0525
Fax Number	:	215-634-8402

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

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	02/03/2012

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