MEDICARE: NORTHEAST PRIMARY CARE, 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	207R00000X	Internal Medicine Physician	MD027187-E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1891882973	OTHER	PA	INDIVIDUAL NPI NUMBER

General Provider Information

NPI Number	:	1760714208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST PRIMARY CARE, PC

Provider Business Mailing Address
First Line	:	8151 REVERE STREET
Second Line	:	1ST FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3002
Country	:	US
Telephone Number	:	215-624-3000
Fax Number	:	215-624-6855

Provider Business Practice Location Address
First Line	:	8151 REVERE ST
Second Line	:	1ST FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3002
Country	:	US
Telephone Number	:	215-624-3000
Fax Number	:	215-624-6855

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. DARIA L. DYKYJ
Credential	:
Telephone Number	:	215-624-3000

Provider Enumeration Date	:	02/09/2010
Last Update Date	:	02/09/2010

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