Provider Demographics
NPI:1801820741
Name:SOUTH PHILADELPHIA FAMILY MEDICINE
Entity Type:Organization
Organization Name:SOUTH PHILADELPHIA FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-334-4049
Mailing Address - Street 1:3960 LANKENAU AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2827
Mailing Address - Country:US
Mailing Address - Phone:215-334-4049
Mailing Address - Fax:215-462-9722
Practice Address - Street 1:2243 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3102
Practice Address - Country:US
Practice Address - Phone:215-334-4049
Practice Address - Fax:215-462-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008840L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA043082Medicare ID - Type Unspecified