Provider Demographics
NPI:1801883723
Name:PERMUT, STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:PERMUT
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-2400
Mailing Address - Fax:215-707-4034
Practice Address - Street 1:1316 W ONTARIO ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5220
Practice Address - Country:US
Practice Address - Phone:215-707-2400
Practice Address - Fax:215-707-4034
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0000797207Q00000X
PAMD-060515-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD060515LOtherFAMILY MEDICINE
PA0016157440002Medicaid
C48674Medicare UPIN