Provider Demographics
NPI:1134148687
Name:KIST, JOSEPH
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:KIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:2 RHOADS PAVILLION
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2737
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:2 RHOADS PAVILION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2737
Practice Address - Fax:215-349-8339
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421236207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100820565Medicaid
PA069770Medicare ID - Type Unspecified
PA100820565Medicaid