Provider Demographics
NPI:1982015236
Name:GANS, ITAI (MD)
Entity type:Individual
Prefix:
First Name:ITAI
Middle Name:
Last Name:GANS
Suffix:
Gender:
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:PO BOX 34990
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:833-941-3871
Practice Address - Street 1:266 LANCASTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3256
Practice Address - Country:US
Practice Address - Phone:610-644-6900
Practice Address - Fax:833-941-3871
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471151207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103792419Medicaid