Basic Information
| Provider Information | |||||||||
| NPI: | 1114095791 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON HEALTH - NORTHEAST | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ARIA HEALTH FRANKFORD CAMPUS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781001 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191781001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154816873 | ||||||||
| FaxNumber: | 2154813985 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 FRANKFORD AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191242618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158312000 | ||||||||
| FaxNumber: | 2158078217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GALUP | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2156125038 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 061801 | PA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 120374 | 01 | PA | AETNA HMO | OTHER | 0001010000 | 01 | PA | KEYSTONE IBC | OTHER | 0073204902 | 01 | PA | AMERICHOICE | OTHER | 00019 | 01 | PA | HEALTH PARTNERS | OTHER | 0001010000 | 01 | PA | PERSONAL CHOICE | OTHER | 4193300 | 01 | NJ | MEDICAID OF NEW JERSEY | OTHER | 60052 | 01 | PA | KEYSTONE MERCY | OTHER | 1007705250010 | 05 | PA | MEDICAID | 6490865 | 01 | PA | AETNA PPO | OTHER |