Provider Demographics
NPI:1174669311
Name:FAMILY MEDICAL SOCIETY A DIVISION OF WOMENS MEDICAL SOCIETY
Entity Type:Organization
Organization Name:FAMILY MEDICAL SOCIETY A DIVISION OF WOMENS MEDICAL SOCIETY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOSNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-382-4300
Mailing Address - Street 1:3801 05 LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2317
Mailing Address - Country:US
Mailing Address - Phone:215-382-4300
Mailing Address - Fax:215-382-3972
Practice Address - Street 1:3801 05 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2317
Practice Address - Country:US
Practice Address - Phone:215-382-4300
Practice Address - Fax:215-382-3972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009422E207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0544746Medicaid
PAG032662Medicare ID - Type Unspecified
PA0544746Medicaid