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257 W Cayuga St Philadelphia PA 19140-2439 | |
| (267) 368-6953 | |
| (215) 621-6940 |
| Full Name | |
|---|---|
| Speciality | Internal Medicine |
| Location | 257 W Cayuga St, Philadelphia, Pennsylvania |
| Authorized Official Name and Position | Fabian A Vengoechea (OWNER & CEO) |
| Authorized Official Contact | 2673686953 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
257 W Cayuga St Philadelphia PA 19140-2439 Ph: (267) 368-6953 | 257 W Cayuga St Philadelphia PA 19140-2439 Ph: (267) 368-6953 |
| NPI Number | 1811449697 |
|---|---|
| Provider Enumeration Date | 10/27/2016 |
| Last Update Date | 03/21/2024 |
| Medicare PECOS PAC ID | 8022398080 |
|---|---|
| Medicare Enrollment ID | O20161208000977 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811449697 | NPI | - | NPPES |
| 103229169 | Medicaid | PA |
| Provider Name | Fabian A Vengoechea |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1033150800 PECOS PAC ID: 2668483330 Enrollment ID: I20060509000564 |
| Provider Name | Lea M Isaac |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1770795106 PECOS PAC ID: 1254409501 Enrollment ID: I20081014000317 |
| Provider Name | Jacqueline M Redman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1063753598 PECOS PAC ID: 6507009255 Enrollment ID: I20130827000831 |
| Provider Name | Yun Mi Kim |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1750938288 PECOS PAC ID: 9739515040 Enrollment ID: I20200205001314 |
| Provider Name | Jessica O'driscoll |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1053846428 PECOS PAC ID: 4385031095 Enrollment ID: I20220427003328 |
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