Provider Demographics
NPI:1366885592
Name:KEIFFER, GINA MARIE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:KEIFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:DEPOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 701
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:215-955-6180
Mailing Address - Fax:215-955-6410
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 701
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-6180
Practice Address - Fax:215-955-6410
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10902500207R00000X
PAMD457966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine