1033259627 NPI number — PENN PRESBYTERIAN MEDICAL CTR DETOX REHAB

Table of content: (NPI 1033259627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033259627 NPI number — PENN PRESBYTERIAN MEDICAL CTR DETOX REHAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENN PRESBYTERIAN MEDICAL CTR DETOX REHAB
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:
1033259627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 MARKET ST
Provider Second Line Business Mailing Address:
UM600
Provider Business Mailing Address City Name:
PHILA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19102-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-796-4640
Provider Business Mailing Address Fax Number:
609-770-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 N 39TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-796-4640
Provider Business Practice Location Address Fax Number:
609-770-7792
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCORMICK
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT VICE PRESIDENT FINANCE
Authorized Official Telephone Number:
215-762-0888

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007297070001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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