Provider Demographics
NPI:1679691711
Name:ULYSEES GAMMAGE JR
Entity Type:Organization
Organization Name:ULYSEES GAMMAGE JR
Other - Org Name:UNIVERSALE PEDORTHIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ULYSEES
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMMAGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-776-0981
Mailing Address - Street 1:6037 CASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-3207
Mailing Address - Country:US
Mailing Address - Phone:215-776-0981
Mailing Address - Fax:215-224-6611
Practice Address - Street 1:6037 CASTOR AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-3207
Practice Address - Country:US
Practice Address - Phone:215-776-0981
Practice Address - Fax:215-224-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000005706332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005113000OtherPERSONAL CHOICE
PA0005113000OtherDURABLE MEDICAL EQUIPTMEN
PA0005113000OtherKEYSTONE EAST
PA0005113000OtherKEYSTONE EAST
PA0005113000OtherPERSONAL CHOICE