Provider Demographics
NPI:1659328672
Name:CHANNELL, RONALD WILLIAM
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WILLIAM
Last Name:CHANNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 E YORK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-2120
Mailing Address - Country:US
Mailing Address - Phone:215-634-0525
Mailing Address - Fax:215-634-8402
Practice Address - Street 1:2314 E YORK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-2120
Practice Address - Country:US
Practice Address - Phone:215-634-0525
Practice Address - Fax:215-634-8402
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002419-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA057806Medicare ID - Type Unspecified
PAT27681Medicare UPIN