Basic Information
| Provider Information | |||||||||
| NPI: | 1255378527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGIDA | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157072433 | ||||||||
| FaxNumber: | 2157073677 | ||||||||
| Practice Location | |||||||||
| Address1: | 7600 CENTRAL AVE | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157282162 | ||||||||
| FaxNumber: | 2157284883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | MD028712E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | MD028712E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | MD028712E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | MD028712E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | MD028712E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | MD028712E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 000912646 | 05 | PA | MEDICAID |