Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | MD017526E | PA |
Y | 2080P0204X | Pediatric Emergency Doctor | MD017526E | PA |
NPI | 1053334862 |
---|---|
Provider Name | Fred M Henretig |
First Address | Philadelphia, PA 19107-3323 |
Second Address | Philadelphia, PA 19104-4319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 19/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000764267 | (05) | PA |
3618501 | (05) | NJ |
B35159 | (02) |