Provider Demographics
NPI:1124473426
Name:BANGOR PODIATRY LLC
Entity type:Organization
Organization Name:BANGOR PODIATRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-588-6621
Mailing Address - Street 1:325 BLUE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1526
Mailing Address - Country:US
Mailing Address - Phone:610-588-6621
Mailing Address - Fax:610-588-6307
Practice Address - Street 1:224 NAZARETH PIKE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-9080
Practice Address - Country:US
Practice Address - Phone:610-351-9244
Practice Address - Fax:610-351-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA332B00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025694980001Medicaid
PA100720Medicare UPIN