Provider Demographics
NPI:1396952206
Name:MANGIN, ELLEN J (DO)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:J
Last Name:MANGIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 YORK RD STE 203
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2872
Mailing Address - Country:US
Mailing Address - Phone:215-886-0174
Mailing Address - Fax:215-886-9217
Practice Address - Street 1:500 YORK RD STE 203
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2872
Practice Address - Country:US
Practice Address - Phone:215-886-0174
Practice Address - Fax:215-886-9217
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015496207R00000X
PAVP004690H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102823860Medicaid
PA020482Medicare PIN
PA565157Medicare UPIN