1780746917 NPI number — PHILADELPHIA MENTAL HEALTH CLINIC

Table of content: (NPI 1780746917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780746917 NPI number — PHILADELPHIA MENTAL HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILADELPHIA MENTAL HEALTH CLINIC
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:
1780746917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1235 PINE STREET
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:
19107-5945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-598-0223
Provider Business Mailing Address Fax Number:
215-598-9020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1235 PINE 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:
19107-5945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-598-0223
Provider Business Practice Location Address Fax Number:
215-598-9020
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARROLL
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
215-735-9379

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  123880 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 265050000 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000138598 . This is a "BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007279540006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0056455000 . This is a "BC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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