Provider Demographics
NPI:1790725703
Name:INNISS, RAQUEL (MD)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:INNISS
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 1:9331 OLD BUSTLETON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4204
Mailing Address - Country:US
Mailing Address - Phone:215-602-8500
Mailing Address - Fax:215-676-6507
Practice Address - Street 1:9331 OLD BUSTLETON AVE STE 201
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4204
Practice Address - Country:US
Practice Address - Phone:215-602-8500
Practice Address - Fax:215-676-6507
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD074296208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01951255Medicaid
PA01951255Medicaid
PAH93687Medicare UPIN