Basic Information
Provider Information | |||||||||
NPI: | 1043434608 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GAUDENZIA DRC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GAUDENZIA DRC OUTPATIENT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | NORRISTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 194014716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102399600 | ||||||||
FaxNumber: | 6102757025 | ||||||||
Practice Location | |||||||||
Address1: | 3200 HENRY AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191291137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159919700 | ||||||||
FaxNumber: | 2159919796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2007 | ||||||||
LastUpdateDate: | 07/19/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOYLE | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | DIR. FISCAL & CORPORATE OPERASTIONS | ||||||||
AuthorizedOfficialTelephone: | 6102399600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | J.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 807384 | PA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261Q00000X | 807384 | PA | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 0019613780008 | 05 | PA |   | MEDICAID |