Basic Information
| Provider Information | |||||||||
| NPI: | 1407054380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NG | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TUCK WOH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | THE WANAMAKE BLDG. 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259538 | ||||||||
| FaxNumber: | 2674259552 | ||||||||
| Practice Location | |||||||||
| Address1: | 34TH & CIVIC CENTER BLVD | ||||||||
| Address2: | THE CHILDREN'S HOSPITAL OF PHILADELPHI | ||||||||
| City: | PHILADELHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901572 | ||||||||
| FaxNumber: | 2155901501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PS0010X | ME113644 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | G0443Z | 01 | FL | MEDICARE PTAN | OTHER |