Provider Demographics
NPI:1952440844
Name:EAST PENN RHEUMATOLOGY
Entity Type:Organization
Organization Name:EAST PENN RHEUMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUDIVICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-868-1336
Mailing Address - Street 1:701 OSTRUM ST
Mailing Address - Street 2:SUITE 501
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1155
Mailing Address - Country:US
Mailing Address - Phone:610-868-1336
Mailing Address - Fax:610-332-3436
Practice Address - Street 1:600 PLAZA CT
Practice Address - Street 2:447 OFFICE PLAZA
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8263
Practice Address - Country:US
Practice Address - Phone:570-424-9153
Practice Address - Fax:570-424-1046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012628E207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
715374Medicare ID - Type Unspecified
PAB39915Medicare UPIN