Provider Demographics
NPI:1780662494
Name:DOHERTY, JEANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 RACE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1125
Mailing Address - Country:US
Mailing Address - Phone:215-587-3159
Mailing Address - Fax:215-587-9405
Practice Address - Street 1:1513 RACE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1125
Practice Address - Country:US
Practice Address - Phone:215-587-3159
Practice Address - Fax:215-587-9405
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067919L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001771060Medicaid
PA260042290Medicare PIN
PAH04436Medicare UPIN
PA001771060Medicaid