Provider Demographics
NPI:1285652255
Name:WOODWARD INTERNAL MEDICINE, INC.
Entity Type:Organization
Organization Name:WOODWARD INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:YACHMENYOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-671-9003
Mailing Address - Street 1:2375 WOODWARD ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-5120
Mailing Address - Country:US
Mailing Address - Phone:215-671-9003
Mailing Address - Fax:215-671-9004
Practice Address - Street 1:2375 WOODWARD ST
Practice Address - Street 2:SUITE 115
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-5120
Practice Address - Country:US
Practice Address - Phone:215-671-9003
Practice Address - Fax:215-671-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061999L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017308530001Medicaid
PA0017308530001Medicaid
PA107459Medicare PIN