Provider Demographics
NPI:1518029461
Name:PHILADELPHIA PODIATRY GROUP
Entity Type:Organization
Organization Name:PHILADELPHIA PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:IEZZI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-336-6600
Mailing Address - Street 1:2428 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4418
Mailing Address - Country:US
Mailing Address - Phone:215-336-6600
Mailing Address - Fax:
Practice Address - Street 1:2428 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:215-336-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002094L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0687240000OtherKEYSTONE HMO