MEDICARE: DR. KATIE DOUGHERTY D.O.

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	207Q00000X	Family Medicine Physician	OS008476L	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	:	1962433649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATIE DOUGHERTY D.O.

Provider Business Mailing Address
First Line	:	2534 S 18TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3701
Country	:	US
Telephone Number	:	215-463-4363
Fax Number	:	215-463-4365

Provider Business Practice Location Address
First Line	:	2534 S 18TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-3701
Country	:	US
Telephone Number	:	215-463-4363
Fax Number	:	215-463-4365

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	01/14/2015

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