Basic Information
| Provider Information | |||||||||
| NPI: | 1104048479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATH, SCIENCE & TECHNOLOGY COMM. CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 BYBERRY RD. | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565051300 | ||||||||
| FaxNumber: | 8565051301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 BYBERRY RD. | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565051300 | ||||||||
| FaxNumber: | 8565051301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8565051300 | ||||||||
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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 | 251300000X | PA | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 1017636410001 | 05 | PA | MEDICAID |