Provider Demographics
NPI:1710251897
Name:FOX CHASE CANCER CENTER MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:FOX CHASE CANCER CENTER MEDICAL GROUP, INC
Other - Org Name:NEURO ASSOC OF FCCC, MGI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-707-3911
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-728-6900
Mailing Address - Fax:215-214-3779
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:FOX CHASE CANCER CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-214-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026888280002Medicaid