Provider Demographics
NPI:1740278829
Name:MANGAN, KENNETH F (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:F
Last Name:MANGAN
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:PO BOX 827783
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7783
Mailing Address - Country:US
Mailing Address - Phone:215-707-4000
Mailing Address - Fax:215-707-5066
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-4000
Practice Address - Fax:215-707-5066
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025673E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008685570001Medicaid
PA0008685570001Medicaid
001664KUSMedicare ID - Type Unspecified