Basic Information
| Provider Information | |||||||||
| NPI: | 1477512788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZUCKERMAN | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE | ||||||||
| Address2: | 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | KLEIN BUILDING SUITE 331 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154566948 | ||||||||
| FaxNumber: | 2154551933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 10/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD045074E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 0012025930002 | 05 | PA | MEDICAID |