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1316 W. Ontario St. Philadelphia PA 19140 | |
| (215) 707-2400 | |
| (215) 707-4034 |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 1316 W. Ontario St., Philadelphia, Pennsylvania |
| Authorized Official Name and Position | Tonya M Woodard (CREDENTIALING/MANAGER) |
| Authorized Official Contact | 2157073911 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2450 W Hunting Park Ave Philadelphia PA 19129-1302 Ph: (215) 707-2400 | 1316 W. Ontario St. Philadelphia PA 19140 Ph: (215) 707-2400 |
| NPI Number | 1811985732 |
|---|---|
| Provider Enumeration Date | 10/13/2005 |
| Last Update Date | 06/15/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811985732 | NPI | - | NPPES |
| 1007780130744 | Medicaid | PA | |
| 1007780130829 | Medicaid | PA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
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