Provider Demographics
NPI:1235403429
Name:FOX CHASE CANCER CENTER MEDICAL GROUP,INC
Entity Type:Organization
Organization Name:FOX CHASE CANCER CENTER MEDICAL GROUP,INC
Other - Org Name:DERM ASSOC OF FCCC, MGI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-707-3911
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:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-728-2191
Mailing Address - Fax:215-707-3992
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:MSO/ENROLLMENT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-2191
Practice Address - Fax:215-214-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
PA207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026888280010Medicaid