Provider Demographics
NPI:1023006053
Name:TAQUI, BIZATH
Entity Type:Individual
Prefix:
First Name:BIZATH
Middle Name:
Last Name:TAQUI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7783
Mailing Address - Country:US
Mailing Address - Phone:215-707-1622
Mailing Address - Fax:215-707-0943
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-1622
Practice Address - Fax:215-707-0943
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0713205L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018327000005Medicaid
H32053Medicare UPIN
PA0018327000005Medicaid