Provider Demographics
NPI:1245243120
Name:MOGHADAM, EILEEN SKROMAK (MD)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:SKROMAK
Last Name:MOGHADAM
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 1:500 S BROAD ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1613
Mailing Address - Country:US
Mailing Address - Phone:215-685-6769
Mailing Address - Fax:215-685-6732
Practice Address - Street 1:4400 HAVERFORD AVE
Practice Address - Street 2:HEALTH CARE CENTER #4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1361
Practice Address - Country:US
Practice Address - Phone:215-685-7600
Practice Address - Fax:215-386-4902
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009737E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011276770001Medicaid
PASK123472Medicare ID - Type Unspecified
PA0011276770001Medicaid