1225546245 NPI number — ELWYN OF PENNSYLVANIA AND DELAWARE

Table of content: (NPI 1225546245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225546245 NPI number — ELWYN OF PENNSYLVANIA AND DELAWARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELWYN OF PENNSYLVANIA AND DELAWARE
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:
6
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:
1225546245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 ELWYN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELWYN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19063-4622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-891-7079
Provider Business Mailing Address Fax Number:
610-891-2964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 HENRY AVE STE 401
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:
19129-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-673-3383
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BUSCH
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DIR. OF CONTRACTING CREDENTIALING
Authorized Official Telephone Number:
445-206-3028

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  143430 , 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: 1000021240674 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com