Basic Information
| Provider Information | |||||||||
| NPI: | 1013367309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VENGRENYUK | ||||||||
| FirstName: | MARIYA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 N 15TH ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157627000 | ||||||||
| FaxNumber: | 2157627765 | ||||||||
| Practice Location | |||||||||
| Address1: | 7600 CENTRAL AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157282276 | ||||||||
| FaxNumber: | 2152144119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 10/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 84258 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MT212010 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD468755 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 302324 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.