1013129709 NPI number — INTERVENTIVE CARE CRISIS MANAGEMENT NETWORK

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 1013129709 NPI number — INTERVENTIVE CARE CRISIS MANAGEMENT NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIVE CARE CRISIS MANAGEMENT NETWORK
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:
Provider Other Organization Name Type Code:
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:
1013129709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 N BROAD ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19140-3610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-225-5566
Provider Business Mailing Address Fax Number:
215-949-3483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 NORTH BROAD STREET
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:
19140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-225-5566
Provider Business Practice Location Address Fax Number:
215-949-3483
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YATES
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
267-994-7752

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  102930 , 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)

  • Identifier: 0016910490001 . This is a "PROMISE MAID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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