Provider Demographics
NPI:1568401792
Name:POTHEL, LOUIS JOSEPH RALPH (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS JOSEPH
Middle Name:RALPH
Last Name:POTHEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 25 VINE STREET
Mailing Address - Street 2:SPECTRUM HEALTH SERVICES INC
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139
Mailing Address - Country:US
Mailing Address - Phone:215-471-2671
Mailing Address - Fax:215-471-1079
Practice Address - Street 1:5619 25 VINE STREET
Practice Address - Street 2:HADDINGTON HEALTH CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139
Practice Address - Country:US
Practice Address - Phone:215-471-2671
Practice Address - Fax:215-471-1079
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013618140001Medicaid
E91517Medicare UPIN
PA1013618140001Medicaid