Basic Information
| Provider Information | |||||||||
| NPI: | 1760507859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHILADELPHIA FIGHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 LOCUST STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157901788 | ||||||||
| FaxNumber: | 2157325490 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 LOCUST ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159854448 | ||||||||
| FaxNumber: | 2156731145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUNGY | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2159854448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100747222 | 05 | PA | MEDICAID | 7365513 | 05 | PA | MEDICAID |