Basic Information
| Provider Information | |||||||||
| NPI: | 1922197961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT STREET EAST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159555800 | ||||||||
| FaxNumber: | 2159234267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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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 | 2080P0205X | MD027633 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | MD027633L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 000666130 | 05 | PA | MEDICAID | 0006661300013 | 05 | PW | MEDICAID | 1537512 | 05 | MD | MEDICAID | 1449702 | 05 | NJ | MEDICAID |