1710160460 NPI number — MERAKEY IDD PHILADELPHIA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710160460 NPI number — MERAKEY IDD PHILADELPHIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERAKEY IDD PHILADELPHIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE ASSOCIATION FOR INDEPENDENT GROWTH, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710160460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 WISSAHICKON AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19144-4248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-320-2040
Provider Business Mailing Address Fax Number:
215-320-2041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6901 OLD YORK RD APT D201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19126-2228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-224-7974
Provider Business Practice Location Address Fax Number:
215-320-2041
Provider Enumeration Date:
12/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TILSON
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CORP SR. DIRECTOR OF BUSINESS OPS
Authorized Official Telephone Number:
215-836-3131

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  126430 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)