Provider Demographics
NPI:1972996189
Name:BANGOR PODIATRY LLC
Entity type:Organization
Organization Name:BANGOR PODIATRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-588-6621
Mailing Address - Street 1:129 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1603
Mailing Address - Country:US
Mailing Address - Phone:610-588-6621
Mailing Address - Fax:610-588-6307
Practice Address - Street 1:1310 ROUTE 209 STE 107
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:PA
Practice Address - Zip Code:18331-7751
Practice Address - Country:US
Practice Address - Phone:570-992-5779
Practice Address - Fax:570-992-5806
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANGOR PODIATRY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-12
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004468L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty