Provider Demographics
NPI:1194362533
Name:MABOU, MEDGINA RAMSES (MHA)
Entity Type:Individual
Prefix:
First Name:MEDGINA
Middle Name:RAMSES
Last Name:MABOU
Suffix:
Gender:F
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W. SOMERSET ST
Mailing Address - Street 2:ESTUERZO PROGRAM
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133
Mailing Address - Country:US
Mailing Address - Phone:215-763-8870
Mailing Address - Fax:215-223-2936
Practice Address - Street 1:216 W. SOMERSET ST
Practice Address - Street 2:ESTUERZO PROGRAM
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133
Practice Address - Country:US
Practice Address - Phone:215-763-8870
Practice Address - Fax:215-223-2936
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100751904001Medicaid