Basic Information
| Provider Information | |||||||||
| NPI: | 1053436212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST TREATMENT CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 499 N 5TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191234005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2154517110 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191371313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2154517110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 06/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | SOLOMONS | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2154517159 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 910194 | PA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 0004972000 | 01 | PA | MAGELLAN-PERSONAL CHOICE | OTHER | 159997 | 01 | PA | BLUE CROSS DELAWARE | OTHER | 046410000 | 01 | PA | MAGELLAN-COMMERCIAL | OTHER | 1007738860035 | 05 | PA | MEDICAID | 273261 | 01 | PA | MANAGED HLTH NETWORK | OTHER | 311749 | 01 | PA | MAGELLAN-KEYSTONE HPE | OTHER |