Provider Demographics
NPI:1851332589
Name:PASSYUNK MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:PASSYUNK MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PISANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-467-0700
Mailing Address - Street 1:1626 E PASSYUNK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-1122
Mailing Address - Country:US
Mailing Address - Phone:215-467-0700
Mailing Address - Fax:215-467-4457
Practice Address - Street 1:1626 E PASSYUNK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-1122
Practice Address - Country:US
Practice Address - Phone:215-467-0700
Practice Address - Fax:215-467-4457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007441L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA767233Medicare ID - Type Unspecified