Provider Demographics
NPI:1164569539
Name:MOUGHAN, BETH (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:MOUGHAN
Suffix:
Gender:F
Credentials:MD
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 2:3/208N
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-5437
Mailing Address - Fax:215-707-5180
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-5437
Practice Address - Fax:215-707-5180
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045676L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001405611Medicaid
PA732638Medicare ID - Type Unspecified
PA001405611Medicaid