Provider Demographics
NPI:1114100336
Name:PENNSPORT INTERNAL MEDICINE GROUP, PC
Entity Type:Organization
Organization Name:PENNSPORT INTERNAL MEDICINE GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WINOKUR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-389-6120
Mailing Address - Street 1:1817 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-1945
Mailing Address - Country:US
Mailing Address - Phone:215-389-3368
Mailing Address - Fax:215-389-1225
Practice Address - Street 1:1817 S 2ND ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19148-1945
Practice Address - Country:US
Practice Address - Phone:215-389-3368
Practice Address - Fax:215-389-1225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003325L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA426882Medicare PIN