Basic Information
| Provider Information | |||||||||
| NPI: | 1497391262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSENZIO | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | SARAH | ||||||||
| NamePrefix: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IP | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | SARAH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558465 | ||||||||
| FaxNumber: | 2159552516 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558465 | ||||||||
| FaxNumber: | 2159552516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2019 | ||||||||
| LastUpdateDate: | 05/07/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT226001 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.