Provider Demographics
NPI:1366491938
Name:BANGOR PODIATRY LLC
Entity Type:Organization
Organization Name:BANGOR PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-588-6621
Mailing Address - Street 1:325 BLUE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1526
Mailing Address - Country:US
Mailing Address - Phone:610-588-6621
Mailing Address - Fax:610-588-6307
Practice Address - Street 1:129 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013-1603
Practice Address - Country:US
Practice Address - Phone:610-588-6621
Practice Address - Fax:610-588-6307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004468L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5739020001Medicare NSC
PA100720Medicare PIN