1053436212 NPI number — NORTHEAST TREATMENT CENTERS

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 1053436212 NPI number — NORTHEAST TREATMENT CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST TREATMENT CENTERS
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:
1053436212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7520 STATE RD
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:
19136-3411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-451-7000
Provider Business Mailing Address Fax Number:
215-451-7110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 BRIDGE ST
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:
19137-1313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-451-7000
Provider Business Practice Location Address Fax Number:
215-451-7110
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAIT
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
215-451-7000

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  910194 , 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: 159997 . This is a "BLUE CROSS DELAWARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 273261 . This is a "MANAGED HLTH NETWORK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 046410000 . This is a "MAGELLAN-COMMERCIAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004972000 . This is a "MAGELLAN-PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007738860035 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 311749 . This is a "MAGELLAN-KEYSTONE HPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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