MEDICARE: DR. KAMBEZE BANAN ETEMAD M.D.

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	2084P0800X	Psychiatry Physician	MD 062906-L	PA

General Provider Information

NPI Number	:	1841312196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAMBEZE BANAN ETEMAD M.D.

Provider Business Mailing Address
First Line	:	111 N 49TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-2718
Country	:	US
Telephone Number	:	215-471-2140
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 N 49TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-2718
Country	:	US
Telephone Number	:	215-471-2140
Fax Number	:

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

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	07/08/2007

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