Basic Information
| Provider Information | |||||||||
| NPI: | 1134386147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DREXEL UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DREXEL NUTRITIONAL COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 219 N. BROAD ST. | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622688 | ||||||||
| FaxNumber: | 2157622689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASTERSON-CARR | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 2152557766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 3501980000 | 01 | PA | IBC (KEYSTONE HEALTH PLAN EAST/PERSONAL CHOICE) GROUP NUMBER | OTHER |