Basic Information
| Provider Information | |||||||||
| NPI: | 1053685289 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE INSTITUTE FOR FAMILY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALTON FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | CL # 4655 | ||||||||
| Address2: | PO BOX 95000 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191954655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452553435 | ||||||||
| FaxNumber: | 8452561881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1894 WALTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104536018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185833060 | ||||||||
| FaxNumber: | 7185833360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2012 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALMAN | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2126330800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE INSTITUTE FOR FAMILY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00903700 | 05 | NY | MEDICAID |