Basic Information
| Provider Information | |||||||||
| NPI: | 1770704850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 N BROAD ST | ||||||||
| Address2: | FL 3 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191071500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108762400 | ||||||||
| FaxNumber: | 2154633820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | PROF. OFFICE BLDG 1 SUITE 400 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108762400 | ||||||||
| FaxNumber: | 6108764308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MB07805800 | NJ | N | Other Service Providers | Specialist | 207RC0000X | OS012390 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 102104615 0002 | 05 | PA | MEDICAID |