Provider Demographics
NPI:1467688671
Name:GENGARO, JAMES R (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:GENGARO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5104
Mailing Address - Country:US
Mailing Address - Phone:610-566-9400
Mailing Address - Fax:610-627-4230
Practice Address - Street 1:1068 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5104
Practice Address - Country:US
Practice Address - Phone:610-566-9400
Practice Address - Fax:610-627-4230
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0014656207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA037276OtherMEDICARE AA #
PA824305OtherBLUE SHIELD AA #
PA1007723500075OtherPROMISE GROUP #
PA440771OtherMLHC AA #