Provider Demographics
NPI:1962656587
Name:CARLOS FONSECA MEDICAL
Entity Type:Organization
Organization Name:CARLOS FONSECA MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOELLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-375-7073
Mailing Address - Street 1:526 PENN ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19602-1096
Mailing Address - Country:US
Mailing Address - Phone:610-375-3000
Mailing Address - Fax:610-372-8030
Practice Address - Street 1:526 PENN ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19602-1096
Practice Address - Country:US
Practice Address - Phone:610-375-3000
Practice Address - Fax:610-372-8030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD03459E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB41907Medicare UPIN
PA444432Medicare PIN