Basic Information
| Provider Information | |||||||||
| NPI: | 1407299902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHALY | ||||||||
| FirstName: | MINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154561825 | ||||||||
| FaxNumber: | 2154565926 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 W TABOR RD FL 4 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154563815 | ||||||||
| FaxNumber: | 2154566803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207LP2900X | MD468282 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103671057 | 05 | PA | MEDICAID |