MEDICARE: RAQUEL INNISS MD

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	208000000X	Pediatrics Physician	MD074296	PA
2	207R00000X	Internal Medicine Physician	MD074296	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790725703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAQUEL INNISS MD

Provider Business Mailing Address
First Line	:	9331 OLD BUSTLETON AVE STE 201
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19115-4204
Country	:	US
Telephone Number	:	215-602-8500
Fax Number	:	215-676-6507

Provider Business Practice Location Address
First Line	:	9331 OLD BUSTLETON AVE STE 201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-4204
Country	:	US
Telephone Number	:	215-602-8500
Fax Number	:	215-676-6507

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	08/11/2022

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Directions to “ RAQUEL INNISS MD” Practice Location

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