Basic Information
| Provider Information | |||||||||
| NPI: | 1134113293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RHA/PENNSYLVANIA NURSING HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROSPECT PARK HEALTH & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 815 CHESTER PIKE | ||||||||
| Address2: | |||||||||
| City: | PROSPECT PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190762322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105866262 | ||||||||
| FaxNumber: | 6105864420 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 CHESTER PIKE | ||||||||
| Address2: | |||||||||
| City: | PROSPECT PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190762322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105866262 | ||||||||
| FaxNumber: | 6105864420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | MARGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6105866262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 162502 | PA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0005798000 | 01 | BLUE CROSS | OTHER | 100728085-0006 | 05 | PA | MEDICAID |