Basic Information
| Provider Information | |||||||||
| NPI: | 1851736631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMBOGI | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | KABERLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | KABERLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | DEPARTMENT OF MEDICINE 3 EAST | ||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108746114 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 SOUTH 9TH STREET | ||||||||
| Address2: | SUITE 740 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556680 | ||||||||
| FaxNumber: | 2155033333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2013 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT203498 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207N00000X | MD461216 | PA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1032933390002 | 05 | PA | MEDICAID |