Provider Demographics
NPI:1922081819
Name:FEBO-SAN MIGUEL, CARMEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:
Last Name:FEBO-SAN MIGUEL
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 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-599-4851
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:401-55 W ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3644
Practice Address - Country:US
Practice Address - Phone:215-291-2500
Practice Address - Fax:214-291-2587
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035396L207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006965410001Medicaid
PA117109Medicare ID - Type Unspecified
PA0006965410001Medicaid