Provider Demographics
NPI:1982015236
Name:GANS, ITAI (MD)
Entity Type:Individual
Prefix:
First Name:ITAI
Middle Name:
Last Name:GANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 LANCASTER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3256
Mailing Address - Country:US
Mailing Address - Phone:610-644-6900
Mailing Address - Fax:
Practice Address - Street 1:266 LANCASTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3256
Practice Address - Country:US
Practice Address - Phone:610-644-6900
Practice Address - Fax:610-644-7160
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDUMPS207X00000X
PAMD471151207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103792419Medicaid