Provider Demographics
NPI:1639581671
Name:GANELES, JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:GANELES
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 1:101 E OLNEY AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:222 STATION PLZ N
Practice Address - Street 2:SUITE 509
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3800
Practice Address - Country:US
Practice Address - Phone:516-663-2381
Practice Address - Fax:516-663-8796
Is Sole Proprietor?:No
Enumeration Date:2014-05-26
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4695092085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program