Basic Information
| Provider Information | |||||||||
| NPI: | 1750744017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODCHARLES | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRAVETZ | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 834 CHESTNUT ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551085 | ||||||||
| FaxNumber: | 2159555041 | ||||||||
| Practice Location | |||||||||
| Address1: | 834 CHESTNUT ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556776 | ||||||||
| FaxNumber: | 2159239189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2016 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME154745 | FL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | MD470669 | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 113820600 | 05 | FL | MEDICAID | ULY01 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |