Basic Information
| Provider Information | |||||||||
| NPI: | 1043698673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANGULY | ||||||||
| FirstName: | TANEETA | ||||||||
| MiddleName: | MINDY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 2 SOUTH | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623606 | ||||||||
| FaxNumber: | 2152432312 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 2 SOUTH | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623606 | ||||||||
| FaxNumber: | 2152432312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2015 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD467235 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.